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Reference  Htbrarp 


STANDARD  WORKS   ON   DENTISTRY, 

PUBLISHED   BY 

P.  BLAKISTON,  SON  &  CO. 


HARRIS,  THE  PRINCIPLES  AND  PRACTICE  OF  DENTISTRY. 
Tenth  Revised  Edition,  with  over  400  Illustrations,  Octavo.  Price,  Cloth,  $6.50. 
Leather  $7.00. 

HARRIS,  A  DICTIONARY  OF  MEDICAL  TERMINOLOGY, 
DENTAL  SURGEKY,  and  the  Collateral  Sciences,  Fourth  Edition.  Revised 
and  Enlarged.    Octavo.    Price,  Cloth,  $6.50.    Leather,  $7.50. 

TAFT'S  OPERATIVE  DENTISTRY.  A  Practical  Treatise,  Fourth  Revised 
and  Enlarged  Edition,  with  136 Illustrations.    Octavo.    Price,  Cloth,  $4. 25.    Leather, 

85.00. 

RICHARDSON'S  MECHANICAL  DENTISTRY.  Third  Enlarged  and 
Improved  Edition,  with  184  Illustrations.  Octavo.  Price,  Cloth,  $4.00.  Leather, 
$4.75. 

TOMES,  DENTAL  ANATOMY,  HUMAN  AND  COMPARATIVE. 
Second  Edition  Enlarged,  with  191  illustrations.    12mo.    Price,  Cloth,  $4.25. 

TOMES,  SYSTEM  OF  DENTAL  SURGERY.  Second  Edition,  with  263 
Illustrations.    Thick  12mo.    Price,  Cloth,  $5.00. 

HANDY,  TEXT-BOOK  OF  HUMAN  ANATOMY.  With  264  Illustra- 
tions.   Octavo.    Price,  Cloth,  »3.00. 

COLE-,  DEFORMITIES  OF  THE  MOUTH  AND  THEIR  TREAT- 
MENT. Third  Edition,  Enlarged  and  Improved,  with  83  Wood  Cuts  and  96  Lith- 
ographic Plates.    Octavo.     Price,  Cloth,  $4.50. 

COLE'S  DENTAL  MECHANICS.  A  Practical  Manual.  Second  Edition,  with 
140  Illustrations.    12mo.    Price,  Cloth,  $&00. 

FLAGG,  PLASTICS  AND  PLASTIC  FILLING.  Numerous  Illustra- 
tions.    Octavo.     Bevelled  Cloth.     Price,  $3.00. 

WEDL'S  PATHOLOGY  OF  THE  TEETH.  With  Special  Reference  to 
their  Anatomy  and  Physiology,  with  105  Illustrations.  Octavo.  Price,  Cloth,  $4.50. 
Leather,  $5.50. 

STOCKEN,  DENTAL  MATERIA  MEDICA  AND  THERAPEU- 
TICS.    Third  Edition,  Revised  and  Enlarged.     12mo.    Price,  Cloth,  $2.50. 

LEBER  &  RHTTENSTEIN,  DENTAL  CARIES  AND  ITS 
CAUSES.  Translated  by  Thomas  H.  Chandler,  D.D.S..M.D.  Illustrated.  Octavo. 
Price,  Cloth,  $1.50. 

HUNTER,  PRACTICAL  MECHANICAL  DENTISTRY.  With  100 
Illustrations.     12mo.    Price,  Cloth,  $2.25. 

SEWELL,  DENTAL  ANATOMY  AND  SURGERY.  With  77  Illustra- 
tions.    12mo.     Price,  Paper  (.'overs,  75  cents.    Cloth,  $1.25. 

WHITE  ON  THE  MOUTH  AND  TEETH.  24  Illustrations.  Price,  Paper 
Covers,  80  cents.    Cloth,  50  cents. 

***  Catalogue  of  Dental  Books  furnished  upon  application. 


PRACTICAL  TREATISE 


OPERATIVE  DENTISTRY. 


J.  TAFT,  M.D.,  D.D.S., 

PROFESSOR  OF  PRINCIPLES  AND  PRACTICE  OF  OPERATIVE  DENTISTRY  IN  THE 

DENTAL  COLLEGE  OF  THE  UNIVERSITY  OF  MICHIGAN, 

RECENTLY  PROFESSOR  OF  OPERATIVE  DENTISTRY  AND  DENTAL  HYGIENE  IN 

THE  OHIO  COLLEGE  OF  DF.NTAL  SURGERY. 


FOURTH  EDITION,  REVISED, 


ONE  HUNDRED  AND  THIRTY-SIX  ILLUSTRATIONS. 


PHILADELPHIA: 

P.    BLAKISTON,    SON    &    CO., 

1012  Walnut  Street. 
18  8  3. 


53 


Entered,  according  to  Act  of  Congress,  in  the  year  1882, 

By  P.  BLAKISTOX,  SON  &  CO., 
In  the  office  of  the  Librarian  of  Congress,  at  Washington. 


PREFACE. 
FOURTH  EDITION. 


In  the  preparation  of  the  Fourth  Edition  of  this 
work,  the  changes  have  perhaps  not  been  so  great  as 
those  in  the  third ;  yet  the  labor  has  involved  a  great 
deal  of  care  and  attention. 

There  has  seemed  no  reason  for  changing  the  gen- 
eral plan  of  the  work.  The  aim  from  the  beginning 
has  been  to  present  the  subjects  embraced  in  such  an 
order  as  will  best  serve  the  interest  of  the  student, 
for  whom  the  work  is  primarily  intended. 

It  has  been  in  many  instances  a  somewhat  difficult 
task  to  decide  as  to  the  rejection  of  some  methods, 
instruments  and  appliances.  It  is  not  always  easy 
to  determine  upon  the  merits  of  the  new  as  compared 
with  the  old  and  tried.  Caution  and  perhaps  wisdom 
dictates  that  those  things  that  have  been  thoroughly 
tested  and  approved,  should  not  be  hastily  thrown 
aside  for  those  of  recent  production,  without  good 
evidence  of  improvement. 


VI  PREFACE — FOURTH    EDITION. 

Within  the  last  five  years  quite  as  large  a  number 
of  new  appliances  and  instruments  have  been  brought 
forth,  as  in  any  equal  period  before,  but  it  yet  remains 
to  be  proven  how  many  of  them  are  better  than  those 
in  use  up  to  that  time.  A  few  doubtless  are,  and  the 
aim  has  been  to  include  all  these  in  the  present 
edition.  Quite  a  number  of  instruments  and  appli- 
ances that  have  been  manifestly  superseded,  have 
been  dropped  from  the  work,  and  only  those  retained 
that  are  valuable  and  efficient. 

Cincinnati,  November,  1882. 


PREFACE. 
THIRD   EDITION 


So  great  have  been  the  changes,  in  almost  every 
branch  of  Dental  Practice,  since  the  publication  of 
the  second  edition  of  this  work,  that  the  labor  in- 
volved in  the  preparation  of  a  new  one  has  been  little 
less  than  the  writing  of  an  entirely  new  work. 

During  the  last  few  years  many  new  instruments, 
appliances  and  modes  of  practice,  have  been  intro- 
duced, that  have  proved  very  valuable,  and  are  in 
use  by  the  profession,  superseding  in  many  cases 
others  less  efficient,  while  others,  again,  have  become 
wholly  obsolete  or  comparatively  worthless.  It  has 
therefore  become  necessary  to  omit  many  illustrations 
with  descriptions  of  them,  but  so  many  more  have 
been  added  that  are  now  regarded  as  desirable  and  of 
great  practical  value,  as  to  greatly  increase  the  whole 
number. 

The  general  scope  and  plan  of  the  work  has  not 
been   changed,  or  any  material  modification  made, 


yiii  PREFACE — THIRD    EDITION. 

except  adapting  it  more  fully  to  the  present  advanced 
state  of  the  science.  An  Appendix  has  been  added, 
presenting  some  subjects  more  fully  than  could  be 
satisfactorily  done  in  the  body  of  the  work. 

The  author,  in  conclusion,  cannot  refrain  from 
expressing  the  hope  that  this  edition  will  be  as  favor- 
ably received  as  the  previous  ones,  and  prove  in- 
strumental in  promoting  the  best  interests  of  the 
profession. 

Cincinnati,  January,  1877. 


PREFACE. 
SECOND   EDITION. 


The  preparation  of  the  present  edition  of  this  work 
has  been  attended  with  more  labor  and  effort  than 
the  author  had  anticipated. 

The  first  edition,  at  the  time  of  its  writing,  was 
designed  to  embody  and  present  the  principles  and 
practice  of  the  profession  in  the  operative  depart- 
ment, in  its  highest  attainment. 

Since  that  time,  however,  so  great  have  been  the 
changes  in  many  points  of  practice  and  application 
of  principles,  that  those  given  as  the  best,  nine  years 
ago,  are  superseded  by  others  and  out  of  use  ;  so  that 
in  many  particulars  the  labor  has  been  almost  equal 
to  the  preparation  of  new  matter. 

The  object  in  this,  as  in  the  former  edition,  has 
been  to  bring  the  work  up  to  the  present  status  of  the 
profession ;  and  though  it  has  been  accomplished 
with  many  misgivings  and  consciousness  of  defects, 
the  author  is  not  without  hope  that  it  may  be  of  value 
to  those  preparing  to  enter  the  profession,  if  not  to 
those  already  in  it. 


CONTENTS. 


CHAPTER  I 


Introduction,    . 
Deposits, 
Tartar, 

Its  Origin, 

Points  of  Deposit, 

Its  Effects, 

Method  of  Removing  it, 
Green  Tartar, . 

Its  Origin, 

Treatment, 
Irregularity, 

Effects,     . 
Atrophy,   . 

The  Cause, 

Effects, 
Exostosis, 

Its  Effects,     . 

The  Cause, 
Denuding, 
Chemical  Abrasion,    . 

The  Cause,     . 
Necrosis  of  the  Teeth, 

Causes, 


PAGE 

17 
18 
18 
19 
20 
22 
23 
25 
26 
28 
28 
30 
30 
32 
33 
33 
35 
35 
36 
38 
39 
40 
42 


CHAPTER  II. 


Caries  of  the  Teeth, 

Predisposing  Causes  of  Caries,    . 
Exciting  Causes  of  Caries, 
Comparative  Liability  to  Decay, 
f  onsequencea  of  Caries, 

Treatment  of  Caries, 


43 
52 
57 
64 
66 
68 


Xll 


CONTENTS. 


CHAPTER  III. 


General  Remarks  on  Filling, 
Materials  for  Filling, 
indestructibility, 
Adaptability, 
Hardness, 
Non-conductor, 
Cohesion, 
f'ulor, 
Lead, 
Tin,    . 
Silver, 
Platinum, 
Gold, 

Various  Preparations  of  Gold, 
Crystal  Gold, 
Amalgam, 

Oxychloride  of  Zinc, 
Oxyphosphate  of  Zinc, 
Non-metallic  Materials, 
Hill's  Stopping, 


PAGE 

74 
78 
7^ 
79 
79 
79 
80 
81 
81 
82 
84 
85 
86 


91 
94 
95 
95 
96 


CHAPTER  IV. 

Instruments  for  Filling,     ..... 

99 

Heavy  Cutting-instruments, 

99 

Drills,  ....... 

101 

Bur  Drills,     ..... 

101 

Common  Drills,   ..... 

104 

Drill  Stocks,  ..... 

106 

Excavators,      ...... 

114 

Of  the  Manufacture  of  Excavators, . 

.      •  119 

Filling  Instruments,    ..... 

121 

The  File, 

134 

The  Use  of  the  File,        .... 

137 

Mode  of  Using  the  File, 

137 

CHAPTER  V. 


Separation  of  the  Teeth, 


142 


CONTENTS. 


Xlll 


CHAPTER  VI. 


Filling  Teeth,  . 

Examination,  . 
Opening  Cavities, 
Removal  of  Decay, 
Forming  Cavities,  ■  . 

Exclusion  of  Moisture, 

Saliva  Pump, 

Silk  Thread, 

Clamps, 

Elastic  Strap, 

Wedges, 

Jarvis's  Separators, 

Chip  Blower, 
Introducing  the  Filling, 
Cylinder  or  Block  Filling, 

Forming  Blocks, . 

Introducing  the  Blocks. 

Pellets,     . 

Cohesive  Foil, 
The  Mallet,      . 
Crystal  or  Sponge  Gold,   . 
Finishing  Fillings, 


PAGE 

.... 

154 

155 

158 

.... 

160 

164 

172 

. 

175 

. 

179 

179 

182 

183 

184 

188 

189 

.... 

194 

195 

. 

198 

•        •       • 

201 

202 

206 

. 

209 

213 

CHAPTER  VII. 

Classification  of  Decayed  Cavities, 

Filling  by  Classes  and  Modifications, 
First  (.'lass,     .... 
Saliva  Pump, 
Filling  with  Foil, 
Cohesive  Foil, 
(  rvstal  Gold,      . 
■ml  Class, 
Third  Class,  . 

Fourth  'lass, 

Fifth  Class, 

Special  '  'uses, 

The  Palatal  portion 


of  the  down  broken  away,  leav- 
ed, 


ing  the  outer  portions  Standing — pulp  not  cx|kis 

Screws  tor  Securing  Fill 
Filling  large  Cavities  on  the  Labial  Surfaces  of  tin- 
Superior  [ncisors,       . 
Porcelain  <  lavity  Stopp< 


217 
219 
219 
225 
227 
229 
231 
234 
237 
242 
253 
259 

260 
264 

265 

H67 


CONTENTS. 


CHAPTER  VIII. 


PAGE 

Pathological  Conditions,           .... 

270 

Sensitive  Dentine,       ..... 

271 

Treatment  of  Inflamed  Dentine, 

274 

Tannin  or  Tannic  Acid, 

277 

Creosote,  or  Carbolic  Acid, 

278 

Nitrate  of  Silver,      .... 

278 

Chloride  of  Zinc, 

280 

Terchloride  of  Gold, 

281 

Arsenious  Acid, 

281 

Alkaline  Caustics,    .... 

284 

CHAPTER  IX. 

Exposed  Pulps,            ..... 

287 

Treatment  of  Exposed  Pulps, 

289 

Destruction  of  the  Pulp, 

302 

Actual  Cautery,   .             .             .   • 

307 

Potential  Cautery,     .... 

308 

Arsenious  Acid,   ..... 

308 

Application,       .... 

310 

Filling  Pulp-cavities  and  Canals, 

315 

Preparing  the  Teeth  and  Roots  for  Filling, 

322 

Dental  Periostitis,       ..... 

331 

Treatment,     ..... 

335 

Alveolar  Abscess,        ..... 

339 

Treatment,     ..... 

344 

CHAPTER  X. 

Pivot  Teeth,            ...... 

353 

Fitting  the  Crown,            .... 

357 

Attachment  of  the  Crown,       .... 

359 

Metallic  Pivots,    ..... 

363 

CHAPTER  XL 


Extraction  of  Teeth, 
General  Remarks, 
Indications  for  Extraction, 
Extracting  Instruments,  . 
The  Key, 


374 
376 
380 
383 
384 


CONTENTS. 


XV 


PAGE 

Forceps,     ...... 

388 

Elevators,        ...... 

400 

Hooks,       ...... 

401 

Screw, .             .            .            .       ■      . 

401 

Gum-lancet,           ..... 

403 

The  Method  of  Lancing  the  Gums,    . 

404 

Extraction  of  the  Teeth,  .... 

406 

Superior  Incisors,            .... 

406 

Superior  Cuspids,      .... 

408 

Superior  Bicuspids,          .... 

409 

Superior  Molars,       .... 

412 

Extraction  of  Roots,        .... 

414 

Superior  Third  Molars, 

415 

Inferior  Incisors,  ..... 

418 

Inferior  Cuspids, 

419 

Inferior  Bicuspids,            .... 

420 

Inferior  Molars,         .... 

421 

Inferior  Third  Molars,     ..... 

425 

Extraction  preparatory  to  the  Insertion  of  Artificial 

Dentures,         426 

Conditions  to  be  observed  in  Extraction, 

428 

CHAPTER  XII. 


Accidents  in  the  Extraction  of  Teeth, 

433 

Hemorrhage,   ..... 

434 

Treatment,     ..... 

4-13 

Fracture  of  the  Alveolus, 

444 

Laceration  of  the  Gums,  .... 

446 

Breaking  the  Teeth,    .... 

447 

Removal  of  a  Wrong  Tooth, 

448 

Dislocation  of  the  Inferior  Maxilla,  . 

450 

Syncope,    ...... 

452 

(II AFTER  XIII. 


Anesthetics, 

Chlorofotm — Ether, 
Nitrous  Oxide, 
Local  Anaesthesia, 

Congelation, 
Extraction  by  Electro-magnetism, 

Application, 


455. 
455 
457 
459 
462 
465 
4C7 


XVI  CONTENTS. 

APPENDIX. 

PA  OK 

Section  A. — Dental  Caries,      ......  469 

"      B. — Dr.  Corydon  Palmer's  Plugging  [nstrumente,         .  480 

«      C.— Mallets, 488 

Electric  Mallet, 491 

Automatic  Plugger  for  Engine,  ....  494 

"       D. — Matrices  for  Proximal  Fillings,         .  .  .  495 


OPERATIVE  DENTISTRY. 


CHAPTER  I. 


INTRODUCTION. 


Introductory  to  the  following  treatise,  some  con- 
sideration of  those  conditions  and  diseases  of  the  teeth 
which  require  the  aid  of  the  dental  surgeon  seems 
appropriate.  To  refer,  however,  to  all  of  these,  or  to 
remark  at  length  upon  any  of  them,  is  not  consistent 
with  the  design  of  this  work,  or  necessary  to  a  proper 
understanding  of  the  subjects  proposed.  Only  those 
affections  which  pertain  to  the  teeth  directly,  and  the 
contiguous  parts,  will  here  be  considered ;  and  the 
latter  only  so  far,  in  the  main,  as  surgical  treatment 
is  concerned.  Nor  will  the  pathology  of  contiguous 
parts  be  introduced  ;  for  the  treatment  of  these  being 
mainly  therapeutic,  rather  than  surgical,  would  in- 
volve a  discussion  of  questions  not  within  the  scope 
of  the  present  volume.  Indeed,  it  is  proposed  merely 
to  speak  of  those  affections  of  the  teeth  which  gener- 
ally suggest  surgical  remedies,  and  which  are  impli- 


18  INTRODUCTION. 

cated  more  or  less  in  the  operations  described  in  the 
following  pages;  and  first,  of 

Deposits. 

In  this  term  are  included  those  calcareous  forma- 
tions commonly  called  tartar,  a  certain  coloring  mat- 
ter denominated  green  or  brown  stain,  and  such  other 
impurities  on  the  teeth  as  result  from  neglect,  the 
use  of  tobacco,  and  like  causes.    The  word 

Tartar 

implies  all  calcareous  deposits  upon  the  teeth.  Of 
this  substance  there  are  several  varieties,  the  more 
obvious  of  which  have  respect  to  color,  composition, 
and  consistence.  In  color,  there  are  all  shades, 
from  a  white,  with  slight  yellow  tint,  to  a  jet  black; 
and  in  consistence,  all  degrees,  from  a  thick,  gummy 
mucus  to  nearly  the  density  of  the  dentine  itself.  The 
color  will,  in  most  cases,  be  indicative  of  the  density, 
the  lightest  shade  corresponding  with  the  softest,  and 
the  darkest  with  the  hardest  consistence ;  there  will, 
however,  be  found  some  variation  in  this  respect. 
The  tenacity  to  the  teeth  is  also  in  proportion  to  the 
density,  the  dense  and  dark  adhering  most  firmly. 
The  character  of  the  surface  of  the  tooth  upon  which 
the  deposit  is  made  somewhat  modifies  the  firmness 


TARTAR.  19 

of  attachment.  The  density  of  the  deposit,  too,  is 
generally  indicative  of  the  rapidity  of  its  formation, 
being  in  an  inverse  ratio  to  this. 

All  the  varieties  of  tartar  are  composed  largely  of 
the  same  materials;  though  the  proportions  vary 
much  in  different  cases — phosphate  and  carbonate  of 
lime,  fibrin,  fat,  and  animal  matter,  being  contained 
in  them  all.  The  fact  that  some  varieties  are  soluble 
in  acids,  and  others  not,  has  been  adduced  to  prove 
that  they  are  entirely  different  in  their  composition. 
This,  however,  is  accounted  for  on  another  hypothesis : 
in  the  softer  varieties  the  phosphate  of  lime  is  so  pro- 
tected by  the  fat  and  the  animal  matter  that,  under 
ordinary  circumstances,  acid  cannot  come  in  contact 
with  it;  but  the  dense  varieties  are  very  soluble,  be- 
cause the  acid  readily  comes  in  contact  with  the  cal- 
careous  material. 

Its  Origin. — The  calcareous  constituents  of  tartar 
are  brought  into  the  mouth  in  a  state  of  solution  in 
the  saliva,  being  secreted  from  the  blood  with  that 
fluid  ;  while  fats  and  other  animal  matter  are  accu- 
mulated from  food,  waste  from  the  surface  of  the  mu- 
cous membrane,  and  other  residual  matter  from  the 
mucus,  mid  perhaps  the  saliva  as  well. 

This  calcareous  material,  which  consists  chielly  of 
phosphate  and  carbonate  of  lime,  is  precipitated  from 
the  saliva  by  the  presence)  influence,  and  operation 
vera!  agencies. 


20  INTRODUCTION. 

The  saliva,  immediately  after  passing  from  the 
ducts  into  the  mouth,  undergoes  a  change  by  absorp- 
tion of  oxygen ;  intermingling  with  mucus  and  va- 
rious foreign  matters  in  the  oral  cavity,  and  variations 
of  temperature,  that  greatly  diminish  its  solvent  power 
for  the  earthy  salts  referred  to.  Precipitation  now 
takes  place,  and  lodgment  is  made  upon  the  most  sus- 
ceptible body  and  point  presented. 

Normal  saliva  always  holds  in  solution  more  or  less 
of  this  material ;  and  sometimes  the  agencies  above 
referred  to  are  not  sufficient  to  reduce  its  solvent 
power  to  the  point  of  precipitation,  or  letting  go  the 
material  held  in  solution.  It  is  very  probable  that  in 
some  cases  the  saliva,  very  soon  after  being  projected 
into  the  mouth,  undergoes  change,  independent  of 
the  causes  of  which  mention  has  been  made,  quite 
sufficient  to  permit  precipitation  of  the  salts  of  lime 
it  contains. 

Persons  of  a  lymphatic  temperament,  or  a  tendency 
toward  it,  with  muscles  of  a  soft,  flabby  texture,  hair 
light,  teeth  of  a  rather  inferior  quality,  and  a  free  flow 
of  saliva,  are  most  subject  to  the  accumulation  of 
tartar;  yet  there  are  conditions  of  almost  all  consti- 
tutions in  which  it  is  freely  formed.  That  it  is  pre- 
cipitated from  the  saliva  is  a  fact  so  easily  demon- 
strated and  so  generally  admitted  that  it  need  not 
here  be  considered. 

Points  of  JDejwsit. — The   points   at  which  salivary 


TARTAR. 


21 


calculus  is  deposited  in  the  greatest  quantities  upon 
the  teeth  are  in  the  vicinity  of  the  orifices  of  the  sali- 
vary ducts ;  and  hence  it  is  found  most  abundant  on 
the  lingual  surfaces  of  the  inferior  anterior  teeth,  and 
on  the  buccal  surfaces  of  the  superior  molars.  Fre- 
quently, also,  it  collects  in  considerable  quantities 
upon  the  external  surfaces  of  the  inferior  front  teeth. 
The  points  to  which  it  most  readily  attaches  are  at 
the  necks  of  the  teeth,  immediately  beneath  the  free 
margin  of  the  gum,  and  at  the  termination  of  the 
enamel  where  it  is  thickest.  A  nucleus  once  formed, 
it  encroaches  upon  the  crown  of  the  tooth,  if  no  means 
are  employed  to  prevent  its  lodgment,  at  a  rate  deter- 
mined by  the  condition  of  the  saliva  and  the  changes 
to  which  it  is  subject,  and  the  amount  of  calcareous 
material  in  it. 

It  is  deposited  first  and  most  abundantly  on  the 
necks  of  the  teeth,  because  here  the  saliva  first  comes 
in  contact  with  these  organs,  and  here  remains  for 
the  longest  periods  and  in  the  largest  quantities.  That 
it  is  precipitated  very  soon  after  the  saliva  enters  the 
mouth,  is  evident  from  the  fact  that  it  is  found  col- 
lected upon  the  superior  molars,  just  in  the  vicinity 
of  the  orifices  of  the  ducts  of  Steno,  where  the  saliva 
cannot  be  retained  for  any  considerable  time,  by 
reason  of  the  position,  but  must  very  soon  pass  along 
upon  the  surfaces  of  the  contiguous  teeth,  on  which 
it  is  generally  found  deposited  in  much  smaller  quan- 


22  INTRODUCTION. 

tities.  Such  is  the  condition  of  the  saliva  sometimes, 
either  from  being  surcharged  with  the  calcareous  ma- 
terial, or  from  weakness  of  solvent  power,  that  pre- 
cipitation takes  place  before  discharge  of  the  saliva 
from  the  ducts;  and  so  masses  of  the  solid  sub- 
stance have  been  found  in  the  duct  passages,  and 
in  a  few  instances  have  been  found  imbedded  in 
the  salivary  glands.  Tumors  are  thus  sometimes 
found  that  seem  involved  in  great  obscurity,  and 
occasion  intense  and  prolonged  suffering. 

Its  Effects. — It  exercises  no  directly  injurious  in- 
fluence upon  the  substance  of  the  teeth,  but  it  is 
highly  prejudicial  to  the  parts  immediately  in  con- 
nection with  them,  and  upon  which  the}'  depend  for 
support.  It  encroaches  upon  the  gums  and  alveoli, 
and  causes  absorption  of  these  important  tissues; 
and  as  they  become  destroyed,  its  encroachments  are 
continued  and  accelerated.  In  some  constitutions 
this  process  goes  on  with  little  or  no  annoyance  to 
the  patient,  while  in  others,  irritation,  inflammation, 
and  even  suppuration  of  the  gums  occur;  and  thus 
their  destruction  is  effected  in  a  twofold  manner.  This 
irritation  and  inflammation  may  extend  to  the  mu- 
cous membrane,  and  involve  all  the  adjacent  parts. 
The  dental  periosteum  will  usually  become  impli- 
cated ;  periostitis  will  ensue,  and  often  suppuration, 
thus  breaking  up  the  attachments  of  the  teeth  even 
before  the  surroundings  are  removed.     The  alveolus. 


TARTAR.  23 

too,  becomes  diseased,  and  in  some  instances  its 
death  and  exfoliation  result.  Salivary  calculus, 
however,  never  induces  caries  of  the  teeth,  nor  even 
favors  it,  except  by  inducing  disease  in  the  surround- 
ing parts.  On  the  contrary,  we  frequently  meet  with 
instances  of  decay  entirely  arrested  and  deposit  of 
tartar  in  the  cavity. 

Persons  of  all  ages  are  subject  to  this  affection ; 
those  past  middle  life  being  most  so,  and  those  ad- 
vanced in  years  sometimes  having  teeth  nearly  cov- 
ered with  tartar,  as  is  shown  in  the  accompanying 

Fig.  1. 


-^>S^ 


illustration.  Occasionally,  to  such  an  extent  do  the 
roots  become  invested  with  it  that  the  teeth  drop 
from  the  sockets.  There  are  some  constitutions 
whose  diathesis  is  favorable  to  a  deposition  of  sali- 
vary calculus  through  life.  Others,  again,  will  be 
entirely  exempt  from  it  till  some  peculiar  constitu- 
tional change  intervenes,  when  it  will  begin  to  be 
rapidly  produced. 

Method,  of  Removing  it. — The  removal  of  salivary 
calculus  is  an  operation  that  does  not  involve  a  great 


24 


INTRODUCTION, 
Fio.  2. 


<? 


amount  of  skill,  but,  with  suitable  ap- 
pliances, is  easily  performed.  There  are 
two  methods  of  effecting  it;  the  one,  that 
of  scaling  and  scraping,  and  the  other, 
that  of  decomposing  the  deposit  by  the 
application  of  an  acid.  The  former  is 
always  to  be  preferred  ;  for,  in  the  latter, 
the  chemical  action  of  the  acid  may  not 
stop  with  decomposition  of  the  deposit, 
but  by  the  same  affinity,  and  nearly  as 
readily,  attacks  the  tooth  itself.  For  the 
removal  of  tartar  instruments  of  various 
forms  and  curves  will  be  necessary, 
adapted  and  adjusted  to  the  various 
shapes  and  situations  of  the  surfaces  to 
be  operated  upon.  The  most  common 
forms  are  represented  in  the  accompany- 
ing figure.  The  blade  of  the  instrument 
should  be  applied  at  a  slightly  obtuse 


GREEN   TARTAR.  25 

angle  with  the  surface  of  the  tooth,  just  beyond  the 
edge  of  the  deposit  next  to  or  beneath  the  gum,  and 
thus  passed  under  the  tartar,  scaling  it  off  to  the 
point  in  such  a  manner  as  not  to  cut  or  abrade  the 
enamel.  Deposits  of  this  substance  on  proximate 
surfaces  of  the  teeth  are  to  be  carefully  observed, 
and  removed  with  instruments  of  attenuated  blades. 
When  the  thick  incrustations  have  been  thus  re- 
moved, the  surface  should  then  be  gently  scraped, 
so  as  entirely  to  clean  off  all  remaining  portions, 
and  afterward  thoroughly  polished  with  fine  pumice, 
Arkansas,  or  rotten-stone,  and  finished  by  burnish- 
ing. During  the  operation  frequent  employment  of 
the  brush  with  water  will  be  required,  to  cleanse  the 
mouth  of  the  detached  material  and  the  increased 
secretions ;  and,  in  general,  the  completion  of  the 
process  will  occupy  more  than  one  sitting.  Since 
this  deposit  often  extends  beneath  the  free  margin 
of  the  gum,  much  care  is  necessary  to  see  that  it  is 
all  removed. 

Green  Tartar. 

This  deposit  has  been  so  referred  to  by  writers,  as 
to  convey  the  impression  that  it  is  of  the  same  gen- 
eric character  as  salivary  calculus.  Such  a  misap- 
prehension is  hardly  pardonable.  The  teeth  of  young 
persons  only  arc  subject  to  this'  affection,  it  being 
often    found  on  those  of  children  three  or  four  years 


26  INTRODUCTION. 

old  ;  appears  on  the  labial  surfaces  of  the  superior 
front  teeth,  and  in  largest  quantity  near  the  mar- 
gin of  the  gum.  It  is  seldom  seen  on  the  inferior 
teeth,  and  only  on  the  anterior  surfaces  of  the  su- 
perior. The  color  of  this  deposit  varies  from  a  light 
brown  to  very  dark,  inclining  to  green.  Wherever 
present,  the  surfaces  of  the  teeth  are  abraded,  and 
when  it  is  of  long  standing,  the  entire  enamel  be- 
neath it  is  destroyed,  and  the  dentine  is  gradually 
involved  in  the  dissolution.  This  effect  upon  the 
teeth  is  not  produced  by  the  coloring  matter  observed 
upon  them,  but  by  an  acid  in  combination  with  this 
material  before  it  is  deposited.  The  stain  is  a  pre- 
cipitate from  this  compound,  and  the  acid,  leaving 
this,  combines  with  the  calcareous  ingredients  of  the 
teeth,  to  their  detriment  as  above ;  but  the  precipi- 
tate is  entirely  innocent,  so  far  as  decomposition  of 
the  teeth  is  concerned. 

Its  Origin. — Green  tartar,  or  stain,  doubtless  has 
its  origin  in  the  mucus,  when  this  is  in  a  particularly 
acid  condition.  That  it  does  not  proceed  from  the 
saliva  is  proved  by  the  fact  that  it  is  never  found 
where  there  is  a  free  flow  of  saliva,  or  where  it  has 
free  access;  but  the  point  of  its  deposit  is  where  the 
saliva  is  less  frequently  present,  being  most  abun- 
dant in  cases  in  which  there  is  a  large  relative 
amount  of  mucus,  and  this  in  a  very  acid  condition. 
But  the  query  might  arise  here,  if  the  mucus  of  the 


GEEEX    TAETAE.  27 

mouth  were  wholly  in  that  condition,  why  would  not 
the  teeth  suffer  from  it  elsewhere  ?  Because,  on  the 
masticating  surfaces  of  the  teeth  the  friction  of  the 
food  will  prevent  it,  and  on  the  inner  surfaces  the 
friction  of  the  tongue ;  besides,  wherever  there  is  a 
free  flow  of  saliva,  this  will  have  a  counteracting  ef- 
fect. Decay  goes  on  very  rapidly,  after  it  has  once 
commenced,  upon  teeth  affected  by  this  deposit. 

There  are  points  of  dissimilarity  between  this 
green  pigment  or  stain  and  salivary  calculus,  that  it 
may  be  well  to  notice.  The  latter  is  from  the  saliva; 
the  former  from  the  mucus  ;  and  hence  the  one  exists 
where  there  is  an  abundant  flow  of  saliva,  and  the 
other  where  the  relative  quantity  of  this  is  small. 
The  calculus  is  deposited  when  the  saliva  is  in  an 
alkaline  condition  ;  the  stain,  when  the  mucus  is  very 
acid.  The  former  is  deposited  in  large  quantities 
and  thick  incrustations,  and  upon  the  surfaces  of  the 
teeth,  and  is  easily  removed  without  detriment  to 
their  substance  ;  whereas  the  latter  is  a  thin  film, 
barely  sufficient  to  stain  the  surface,  and  yet  it 
erodes  the  enamel,  and  cannot  be  removed  without 
detaching  some  portion  of  the  latter.  The  one  seems 
rather  preventive  of  caries,  which  does  not  occur 
beneath  it;  but  the  other  is  highly  promotive  of 
decay.  With  these  marked  features  of  difference,  it 
urprising  that  the  two  should  ever  have  been 
confounded,  since  it  is  so  important  that  the  distinc- 


28  INTRODUCTION. 

tive  character  of  each  be  understood,  in  order  to  its 
correct  treatment. 

Treatment — In  order  to  a  perfect  and  final  remedy 
for  green  stain,  systemic  treatment  must  be  combined 
with  the  operative  and  topical ;  but  only  the  latter 
will  be  here  described,  which  has  for  its  object  the 
removal  of  the  deposit,  and  the  rendering  of  the 
eroded  surface  smooth  and  polished.  There  are  two 
or  three  methods  of  accomplishing  this  object.  When 
the  erosion  is  but  slight,  it  can  be  effected  with 
Hindostan  or  Arkansas-stone,  or  pulverized  pumice 
and  water,  applied  with  a  wooden  polisher  of  the 
proper  form  till  the  stain  disappears,  and  then  polish 
with  rotten-stone.  But  when  the  erosion  is  too 
extensive  to  be  thus  reduced,  it  must  be  cut  down 
with  a  corundum  wheel  or  cone,  and  then  finished 
with  stone  as  before.  And  when  the  erosion  is 
extreme,  a  cutting-instrument  may  properly  precede 
the  corundum. 

Irregularity. 

By  this  term  is  implied  those  variations  from  a 
beautiful  and  natural  position  in  which  the  teeth  are 
so  frequently  found.  The  principal  cause  of  irregu- 
larity is  a  disproportion  between  the  size  of  the  arch 
and  the  space  required  for  the  accommodation  of  the 
teeth.  When  this  disproportion  exists,  the  teeth 
which  are  first  erupted  usually  occupy  very  nearly 


IRREGULARITY.  29 

their  proper  position  :  but  those  which  come  after- 
ward are  more  or  less  disarranged,  in  proportion  to 
the  pre-occupation  of  the  space.  There  are  cases  in 
which  the  roots  of  the  temporary  teeth  are  not 
absorbed,  and  the  permanent  teeth  are  erupted  out  of 
their  true  position,  even  when  there  is  room  enough 
for  them  were  the  former  removed.  Irregularity  is 
mainly  confined  to  the  ten  anterior  teeth  of  each 
jaw,  and  usually  to  the  six  front  teeth,  and  consists 
in  either  an  inward  or  an  outward  inclination,  and 
in  some  instances  both.  Sometimes  the  incisors  are 
turned  in  the  socket,  so  that  the  edge  stands  at  a 
very  considerable  angle  with  the  proper  position. 

The  upper  teeth  are  oftener  materially  disarranged 
than  the  lower,  though  the  latter  frequently  exhibit 
some  irregularity,  in  consequence  of  a  crowded  con- 
dition. The  teeth  most  liable  to  be  out  of  position 
are  the  cuspidate.  These,  of  the  permanent  teeth, 
are  the  last  in  their  eruption  ;  and  it  often  occurs  that 
the  arch  is  previously  well-nigh  occupied,  in  which 
case  they  are  thrown  outward.  When  there  is  any 
irregularity  of  the  bicuspids,  it  is  usually  that  of 
ati  inward  inclination,  though  they  are  sometimes 
turned  upon  their  axes.  The  first  and  second  molars 
are  very  seldom  out  of  proper  position.  The  third 
molars,  for  want  of  room,  are  sometimes  thrown  out 

toward  the   cheek,  or  tip    forward,  ami   come   in   e.in- 
tacl     with     the    posterior   side-    of    the    second    molar. 


30  INTRODUCTION. 

and  further  growth   is  not  possible,  or  they  may  be 
prevented  from  coming  out  at  all  in  any  direction. 

Effects. — In  all  cases,  irregularity  is  favorable  to 
decay.  It  is  even  maintained  by  some  that  the  organic 
structure  of  irregular  teeth  is  less  perfect  than  that 
of  regular,  because  the  former  are  impeded  in  their 
eruption,  and  thus  impaired.  But  this,  to  say  the 
least,  is  questionable  ;  for  it  will  be  remembered  that 
the  crowns  of  the  teeth  are  formed  and  ossified  before 
they  can  be  much  affected  by  a  crowded  state ;  and 
it  is  hardly  probable  that  they  could  be  materially 
modified  in  their  structure  after  this  period.  The 
crowns  of  the  teeth  are  rarely  if  ever  deformed  by  a 
crowded  condition.  The  principal  reason  of  the  lia- 
bility of  irregular  teeth  to  decay,  is  the  facility  they 
furnish  for  the  lodgment  of  foreign  substances  about 
them,  and  the  difficulty  they  present  to  its  removal. 
And,  again,  in  irregular  teeth,  parts  are  approximated 
that  nature  did  not  intend  should  be  brought  together. 
Irregularity  impairs  the  speech,  impedes  mastication, 
and  often  distorts  the  countenance  and  deforms  the 
features. 

Atrophy. 

This  affection  is  characterized  by  defective  spots  in 
the  enamel, — white,  chalk-like, — which  scarcely  ever 
penetrate  the  dentine.  In  these  spots  there  is  little 
or  nothing  of   that   organic   structure  exhibited   by 


ATROPHY.  31 

well-formed  enamel.  They  are  usually  small,  but 
vary  greatly  in  number.  They  are  often  found  ar- 
ranged in  transverse  rows  across  the  tooth  affected. 
The  superior  incisors  are  most  frequently  affected 
with  atrophy,  though  the  bicuspids  and  molars  some- 
times exhibit  it.  The  front  upper  teeth  are  attacked 
by  it  only  on  the  anterior  surfaces. 

Instead  of  the  spots,  sometimes  pits  or  indenta- 
tions into  or  through  the  enamel  are  found,  which 
occasionally  run  together,  so  as  ultimately  to  form 
transverse  grooves  of  considerable  extent  upon  the 
teeth.  In  many  cases,  where  on  the  eruption  of  the 
teeth  the  spots  only  are  presented,  the  organs  are  not 
injured,  except  in  appearance,  the  spots  retaining 
the  smooth,  enamel-like  surface  during  life.  In  other 
cases,  the  spot  is  of  such  a  soft,  friable  texture,  that 
it  early  crumbles  out3  leaving  the  pits  above  referred 
to.  These  indentations,  however,  sometimes  exist  at 
the  first  appearance  of  the  tooth,  but  more  frequently 
afterward,  being  formed  by  the  disintegration  of  the 
defective  portion.  Atrophy  is  sometimes  shown  in 
the  shrivelled,  and  more  or  less  corrugated  condition 
of  the  enamel   upon  the  ends  of  the  teeth. 

Atrophy  usually  occurs  on  teeth  of  good  structure, 
short,  thick  crowns,  and  rather  yellowish  color.  The 
long,  thin,  white  tooth,  of  imperfect  organization  and 
insufficient  density,  but  seldom,  if  ever,  presents  an 
atrophied  condition. 


32  INTRODUCTION. 

The  Cause. — It  may  be  difficult  to  point  out  the 
precise  cause  of  this  affection,  but  some  tacts  in  re- 
gard to  it  are  very  obvious.  There  is  in  every  case 
an  obstruction  in  the  development  of  the  enamel  at 
the  point  of  defect,  and  at  the  time  of  its  organiza- 
tion. In  some  cases,  doubtless,  there  is  a  deficient 
amount  and  an  inferior  quality  of  the  materials  elab- 
orated for  the  upbuilding  of  the  structure;  and  this 
is  probably  the  case  when  the  pits  exist  at  the  erup- 
tion of  the  teeth.  In  other  cases,  the  requisite  quan- 
tity of  materials  may  be  elaborated,  and  yet  the  vital 
energy  be  insufficient  to  organize  it,  as  in  the  case 
of  the  spots  referred  to.  The  latter  condition  is  more 
frequent  than  the  former,  as  is  evidenced  by  the 
more  frequent  appearance  of  the  spots  than  of  the 
pits.  We  are  led  to  infer,  then,  that  the  origin  of 
this  affection  is,  for  the  most  part,  constitutional, 
and  not  local.  There  are  commonly  found  traces  of 
it  on  all  the  teeth  whose  enamel  was  in  process  of 
formation  at  the  time  of  the  interruption. 

Any  general  disturbance,  such  as  to  interrupt  the 
assimilative  process,  would  be  detrimental  to  the  per- 
fect formation  of  the  tooth.  Again,  some  affections 
may  materially  affect  the  organizing  ability  of  the  sys- 
tem without  interfering  with  the  assimilative  power. 
Any  disease  that  interrupts  the  functions  of  the  di- 
gestive apparatus  is  prejudicial  to  the  process  of  as- 
similation; whilst  other  diseases,  such,  for  instance, 


EXOSTOSIS.  33 

as  those  of  a  febrile  character,  would  diminish  the 
vital  power,  and  consequently  the  ability  to  build  up 
organic  structures  without  interrupting  in  any  special 
manner  the  process  of  assimilation.  These  things 
are  referred  to  here  for  the  purpose  of  showing  under 
what  circumstances  atrophy  of  the  teeth  may  occur. 
Effects. — In  the  best  formed  teeth  there  are  no  un- 
pleasant results  from  atrophy  other  than  its  detrac- 
tion from  their  beauty,  and  sometimes  being  the  oc- 
casion of  decay.  The  spots  are  unsightly,  and  when 
the  pits  are  present  they  become  dark,  and  sometimes 
black,  from  deposit,  which,  by  ordinary  means,  is 
difficult  of  removal.  In  teeth  of  inferior  structure 
decay  often  supervenes  in  these  pits,  and,  extending 
thence,  involves  the  other  parts;  and  anything  that 
will  affect  the  tooth-substance  will  find  a  beginning- 
place  in  these  spots. 

Exostosis. 

This  term,  critically  defined,  implies  outgrowth  from 
a  bone;  but,  as  applied  to  the  bones  generally,  and 
particularly  to  the  teeth,  it  probably  conveys  the 
idea  of  growth  upon  the  bone.  The  affection  thus  de- 
nominated is  common  to  all  the  bones;  some,  how- 
ever, being  more  frequently  attacked  by  it  than 
others.  It  occurs  upon  the  roots  of  the  teeth,  but  is 
never  developed  where  there  is  no  periosteum.  It  is 
so  nearly  allied  in  structure  and  character  to  the  ce- 

3 


34  INTRODUCTION. 

mentum  that  covers  the  roots  of  the  teeth  that  it  may 
be  regarded  as  hypertrophy  of  that  tissue.  The 
manner  of  its  accumulation  is  not  uniform,  hut  it 
commonly  consists  of  an  enlargement  on  the  point 
of  the  root,  or  from  the  point  some  distance  toward 
and  occasionally  all  the  way  to,  the  neck  of  the  tooth. 
In  some  cases  it  extends  entirely  round  the  root,  and 
in  others  is  confined  to  one  side.  It  sometimes  re- 
sults in  such  an  enlargement  of  the  root,  especially 
if  it  is  near  the  point,  as  to  render  the  tooth  very 
difficult  of  removal.  When  the  root  is  bulb-form,  its 
attachments  may  be  broken  up,  so  as  to  allow  it  to 
rotate  in  the  socket,  and  yet  be  very  difficult  to  re- 
move ;  indeed,  in  some  instances  impossible,  without 
cutting  away  a  portion  of  the  process. 

The  density  of  the  deposit  does  not  vary  much 
from  the  primary  cementuin  of  the  root  on  -which  it 
is  found,  though  in  this  respect  there  is  sometimes 
slight  variation ;  in  a  few  instances  we  have  found 
it  softer  than  the  normal  cementum.  The  tooth 
socket  is  enlarged,  chiefly  by  absorption  for  its  ac- 
commodation. The  color  of  the  substance  is  slightly 
yellow,  not  differing  much  from  that  of  the  root 
itself ;  but  sometimes  it  exhibits  a  semi-translu- 
cent appearance.  The  rate  of  its  formation  varies 
considerably,  sometimes  increasing  so  rapidly  as  to 
occasion  difficulty,  by  impingement  upon  the  sur- 
rounding structure,  especially  upon  nerve  branches, 


EXOSTOSIS.  35 

and  at  other  times  seeming  to  advance  very  slowly; 
and  frequently  it  is  arrested  altogether.  Roots  are 
often  found  affected  with  exostosis  that  have  been 
dead  and  crownless  for  a  number  of  years,  and  yet 
have  never,  so  far  as  known,  given  any  trouble 
because  of  the  affection.  Teeth  perfectly  healthy  in 
other  respects  may  be  thus  affected. 

Its  Effects. — It  usually  increases  the  difficulty  of 
removing  the  tooth,  either  by  enlargement  of  the 
point  of  the  root  or  by  deposit  upon  one  side  of  it, 
causing  it  to  curve  ;  in  which  latter  case  the  difficulty 
is  all  the  greater,  from  the  impossibility  of  deter- 
mining the  direction  of  the  curve.  It  sometimes 
produces  a  diseased  condition  of  the  surrounding 
parts — in  some  instances  chronic  inflammation — that 
may  continue  as  long  as  the  tooth  remains.  Nervous 
affections  often  result  from  exostosis,  either  through 
irritation,  caused  by  pressure  on  the  pulp,  or  through 
the  diseased  condition  of  the  surrounding  parts.  The 
floor  of  the  antrum  is  sometimes  absorbed  away,  in 
consequence  of  the  enlargement  of  the  point  of  the 
root ;  and  then  disease  of  the  lining  membrane  of 
that  cavity  may  occur. 

The  GiK.se. — The  cause  of  this  affection  is  not  well 
understood;  though  much  light  has  been  thrown 
upon  it  by  tie-  researches  upon  the  reproduction  of 
bone,  and  especially  so  far  as  the  function  of  the 
periosteum   is  concerned.     It  is  most  probably  de- 


36  INTRODUCTION. 

posited  by  the  periosteum  when  this  is  in  a  state 
of  irritation;  but  what  particular  condition,  is  not 
clearly  ascertained,  though  some  have  supposed  it  to 
be  inflammation.  It  is  manifest,  however,  that  some- 
thing different  from  a  state  of  simple  inflammation 
exists;  for  there  is  inflammation  in  numerous  in- 
stances without  this  deposit.  Again,  in  all  cases 
where  there  is  periostitis,  that  state  is  definitely  indi- 
cated by  percussion  upon  the  affected  tooth ;  indeed, 
in  the  occlusion  of  the  jaws,  pain  is  usually  experi- 
enced. Yet  there  are  found  many  teeth  whose  roots 
are  subjects  of  this  deposit,  that  have  never  given 
any  indications,  either  by  pain  or  otherwise,  of  a  dis- 
eased condition. 

This  subject  is  one  in  which  there  is  room,  at  least 
so  far  as  dentists  are  concerned,  for  more  definite 
observation. 

Denuding. 

This  consists  in  a  wasting  away  of  the  enamel  of 
the  anterior  teeth,  from  the  points  toward  the  necks. 
The  affection,. .however,  is  of  too  rare  occurrence  to 
demand  extended  consideration.  The  color  of  the 
enamel  is  not  changed  by  this  process,  nor  is  its 
natural  polish  impaired  by  abrasion.  The  dentine, 
on  becoming  exposed  by  this  removal  of  its  natural 
protection  or  covering,  is  perfectly  smooth,  but  of  a 
yellowish    cast,  in   some  cases   inclining   to   brown. 


DENUDING.  37 

When  the  enamel  is  removed,  there  seems  to  be  a 
cessation  of  the  destructive  process ;  for  the  crowns 
of  such  teeth  will,  in  many  instances,  endure  for  a 
long  time — indeed,  till  they  are  worn  down  by  the 
friction  in  mastication. 

This  wasting  process  usually  begins  at  the  points 
of  the  teeth,  and  proceeds  toward  the  necks,  on  all 
sides,  till  the  enamel  is  entirely  destroyed.  Some- 
times, however,  it  commences  on  their  labial  surfaces; 
this  is  particularly  the  case  with  the  superior  an- 
terior, but  very  seldom  with  the  inferior  teeth.  The 
affection,  however,  attacks  the  inferior  more  fre- 
quently than  the  superior  teeth;  yet  it  is  found 
assailing  both  with  about  equal  energy. 

The  cause  of  this  affection  is  not  well  understood, 
though  it  is  generally  conceded  to  be  by  the  opera- 
tion of  an  acid  contained  in  the  mucus ;  and  this, 
with  but  little  doubt,  is  the  source  of  the  agent ;  for 
the  destructive  process  usually  occurs  where  there 
is  a  large  relative  amount  of  this  secretion ;  but  that 
it  is  an  agent  of  a  very  decided  acid  character,  we  are 
not  prepared  to  affirm.  Decay  of  the  teeth  does  not 
seem  to  progress  with  greater  rapidity  while  this 
affection  exists  than  at  other  times;  and  again,  the 
enamel  does  not  present  the  roughened,  abraded  ap- 
pearance resulting  from  the  operation  of  any  ordinary 
agent.  With  these  apparently  incongruous  facts,  it 
is  rather  difficult  to  arrive  at  a  definite  conclusion  as 


38  INTRODUCTION. 

to  the  precise  manner  in  which  this  condition  is  pro- 
duced, or  the  exact  character  of  the  agent  instru- 
mental in  its  production. 

Chemical  Abrasion. 

This  consists  in  a  gradual  destruction  of  the  entire 
substance  of  the  crown  of  the  tooth — the  enamel  and 
the  dentine.  It  is  an  affection  of  comparatively  rare 
occurrence.  It  attacks  the  superior  more  often  than 
the  inferior  teeth,  though  both  are  subject  to  it.  It 
begins  upon  the  points  of  the  central  incisors,  wasting 
them  away  more  rapidly  at  the  median  line,  from 
which  it  progresses  each  way,  involving  the  lateral 
incisors,  cuspids,  and  sometimes  the  bicuspids,  so  that 
a  curved  line  is  presented  by  the  edges  of  the  teeth, 
of  greater  or  less  inclination,  according  to  the  rapidity 
of  the  process.  When  the  superior  teeth  only  are 
affected,  the  opening  between  the  ends  of  the  upper 
and  of  the  lower  front  teeth,  when  closed,  is  a  semi- 
ellipsis.  If  the  inferior  teeth  are  affected,  as  is  some- 
times the  case,  then  the  opening  will  be  an  ellipsis. 

In  the  case  of  Mr.  G.,  the  affection  had  been  pro- 
gressing about  two  years  and  a  half;  the  wasting  away 
extended  to  the  first  bicuspids  both  above  and  below; 
and  when  the  jaws  were  closed,  the  ends  of  the  upper 
and  of  the  lower  central  teeth,  were  about  one-third 
of  an  inch  asunder,  and  the  opening  was  of  the  ellip- 


CHEMICAL  ABRASION.  39 

tical  form.  It  was  a  mystery  to  him.  Two  years 
and  a  half  before,  his  anterior  teeth  shut  close  to- 
gether on  the  ends.  He  had  not  used  them  in  the 
mastication  of  his  food,  for  his  molar  teeth  were  all 
good,  and  sufficient  for  this  purpose ;  and,  moreover, 
it  had  been  impossible  for  him  to  use  them  in  masti- 
cation, since  he  could  not  bring  them  together;  and 
he  had  not  been  in  the  habit  of  using  them  upon  any 
hard  substance. 

The  Cause. — The  cause  of  this  affection,  like  that 
of  denuding,  is  not  well  understood.  It  is  supposed, 
however,  to  be  induced  by  an  acid  contained  in  the 
mucus.  If  this  supposition  is  correct,  it  must  be 
some  acid  with  whose  nature  we  are  but  little,  if  at 
all,  acquainted;  or,  if  any  ordinary  acid,  it  certainly 
must  be  modified  by  very  peculiar  circumstances,  so 
that  it  effects  a  solution  of  both  the  animal  and  the 
earthy  constituents.  The  surface  upon  which  it  acts 
is  always  perfectly  smooth  and  polished,  never  pre- 
senting that  roughened  and  abraded  appearance 
caused  by  the  action  of  any  ordinary  acid  upon  en- 
amel or  dentine.  And  again,  if  this  affection  results 
from  the  operation  of  an  acid  in  the  mucus,  why  does 
not  this  acid,  to  some  extent  at  least,  affect  the  teeth 
at  other  points?  Such  is  not  the  fact;  and  caries 
thai  has  previously  commenced  at  other  points  on  the 
teeth,  does  not  progress  more  rapidly  during  the  ex- 
istence of  this  disease  than  before;  but  it  certainly 


40  TNTIIOpn  TIOX. 

would  if  there  were  a  large  quantity  of  acid  in  the 
mucus. 

It  has  been  supposed  that  the  mucous  follicles  of 
that  part  of  the  tongue  which  comes  in  contact  with 
the  teeth  at  the  affected  part,  are  the  agents  that 
produce  the  disease.  Of  this,  however,  there  is  not 
evidence  sufficient  to  warrant  an  adoption  of  the 
theory.  The  cupping  of  the  molars  and  bicuspids 
bears  strong  indications  of  being  an  analogous  pro- 
cess, and  yet  no  such  influence  can  there  operate  for 
its  accomplishment.  We  have  no  theory  on  this  sub- 
ject to  present,  regarding  it  as  still  an  open  field  for 
investigation.  There  can  be  little  doubt,  however, 
that  the  cause  of  denuding,  of  chemical  abrasion,  and 
of  cupping,  has  its  origin  in  the  constitution,  is  not 
merely  local,  and  its  arrest  must  be  effected,  chiefly 
by  constitutional  treatment. 

Necrosis  of  the  Teeth. 

By  this  term  is  understood  the  death  of  the  part 
involved.  It  has  been  remarked  that  the  condition 
is  similar  to  mortification  in  the  soft  parts.  But  in 
the  latter  there  occurs  a  change  of  structure,  whereas 
in  the  bones,  and  particularly  in  the  teeth,  there  is 
not  necessarily  any  immediate  structural  change  con- 
sequent on  the  loss  of  vitality.  The  teeth  have  their 
organic  connection  with  the  surrounding  parts  by  the 


NECROSIS    OP   THE   TEETH.  41 

external  and  the  internal  periosteum  and  the  pulp ; 
their  crowns  depend  chiefly  for  vitality  upon  the  in- 
ternal organism,  as  is  evident  from  the  total  loss  of 
sensibility  in  them  immediately  after  the  destruction 
of  the  pulp. 

Necrosis  of  the  teeth  diners  from  that  of  the  other 
bones  in  some  particulars,  one  of  the  most  obvious 
of  which  is,  that  in  the  former  there  is  no  exfo- 
liation, the  living  structure  not  having  the  power 
to  throw  oft1  the  dead  or  necrosed  portion.  Again, 
a  dead  part  in  contact  with  the  living  does  not  ma- 
terially affect  it.  The  roots  of  the  teeth  depending 
for  their  vitality  upon  both  their  internal  and  their 
external  connections,  the  former  of  these  connections 
may  be  destroyed  without  materially  affecting  the 
latter.  Thus,  a  tooth  may  be  partially  necrosed, — 
that  is,  vital  in  one  part  and  dead  in  another, — 
without  immediate  injury  to  the  living  portion,  and 
without  separation  of  the  living  from  the  dead.  It 
is  a  happy  provision  that  the  analogy  between  the 
teeth  and  the  other  bones  does  not,  in  this  respect, 
obtain,  for  if  it  did,  we  should  find  the  crowns  of  the 
teeth  separated  from  the  roots  in  all  cases  immedi- 
ately after  the  death  of  the  pulp. 

There  results  but  little  change  of  color  to  the  teeth 
from  necrosis,  unless  coloring  matter  is  absorbed  by 
the  dentine  from  the  decomposed  pulp;  though,  of 
course,  the  Life-like  lustre  and  appearance  of  the  liv- 


42  INTRODUCTION. 

ing  teeth  are  not  present.  Total  necrosis  destroys 
the  entire  organic  connection  of  the  teeth  with  the 
surrounding  parts,  in  which  case  they  are  very  soon 
expelled  from  their  sockets  as  useless. 

Causes. — Caries  is  a  very  common  cause  of  ne- 
crosis, especially  the  partial  form  of  it  to  which  ref- 
erence is  made  above.  Protracted  fever,  or  diseases 
of  any  kind  that  diminish  the  vitality  of  the  system, 
will,  in  a  corresponding  degree,  diminish  that  of  the 
teeth,  and  sometimes  destroy  it  entirely.  Excessive 
medication,  especially  with  mercurials,  will  some- 
times produce  partial,  and  occasionally  total,  necro- 
sis, as  will  also  blows  or  violent  shocks,  even  when 
these  are  not  sufficient  to  displace  the  teeth.  Sudden 
and  extreme  thermal  changes  have  been  reckoned 
causes  of  this  affection,  but  it  may  well  be  doubted 
whether  they  are  adequate  without  the  concurrence 
of  other  influences. 


CHAPTER   II. 

CARIES      OF      THE      TEETH. 

Notwithstanding  the  teeth  are  so  important  in  the 
human  economy,  having  functions  so  various  and  so 
extensive  to  perform,  they  are  greatly  neglected  in 
most  instances,  and  in  many  subjected  to  positive 
violence,  as,  for  example,  in  crushing  or  biting  hard 
substances,  sustaining  weights  and  suffering  severe 
blows,  sudden  extremes  of  temperature,  bungling 
dental  operations,  etc.  Very  few  give  that  attention 
to  these  organs  which  is  requisite  to  preserve  them 
from  injurious  influences;  and  owing  to  artificial 
modes  of  life,  and  consequent  impairment  of  health, 
this  is  often  difficult  to  do.  Indeed,  these  influences 
are  frequently  not  known,  and  the  causes  of  disease 
in  the  teeth  not  explored. 

Such  is  the  truth,  to  some  extent,  in  regard  to 
caries,  though  this  affection  is  more  generally  a  re- 
sult of  conditions  well  understood.  The  dentine  is 
affected  more  frequently  by  caries  than  by  any  other 
form  of  disease.  It  is  both  frequent  in  occurrence 
and  fatal  in  tendency.  Scarcely  any  that  have  at- 
tained maturity  are  exempt  from  its  ravages.  It  is 
a  disease  which  the  vital  forces,  owing  to  the  nature 


44  CARIES   OF   THE   TEETH. 

of  the  tissue,  can  but  feebly  withstand,  at  least  with 
far  less  efficiency  than  in  more  highly  organized  struc- 
tures, and  the  restorative  process  is  wholly  inopera- 
tive here.  Some  maintain  that  softened  dentine  does, 
in  many  cases,  regain  its  normal  density;  but  this 
can  hardly  be,  unless  it  retains  some  degree  of  vi- 
tality, except  possibly  by  infiltration.  But  any  agent 
possessed  of  sufficient  energy  to  decompose  the  den- 
tine will  destroy  its  vitality ;  yet,  a  partial  removal  of 
lime  salts  is  not  always  incompatible  with,  or  destruc- 
tive to  vitality;  in  such  cases  the  normal  density  of  the 
affected  part  maybe  fully  restored, and  even  increased 
growth  has,  in  a  few  instances,  been  observed.  In 
decay,  there  is  a  lack  of  vital  power  to  maintain  the 
integrity  of  the  organic  structure,  or  there  is  the  ac- 
tion of  some  agent  having  an  affinity  for  a  certain 
part  of  the  dentine  more  potent  than  that  vital 
power.  In  either  case  the  vitality  is  destroyed.  In 
an  organized  structure  the  entire  removal  of  one  of 
its  essential  constituents  occasions  a  loss  of  vitality. 

Caries  usually  makes  its  first  attack  upon  the 
dentine,  and  progresses  most  rapidly  in  the  direc- 
tion of  the  tubuli.  There  are  variations  from  this 
course;  as,  for  example,  in  the  large  superficial  caries 
on  the  labial  surfaces  of  the  superior  incisors.  In 
many  cases,  too,  it  extends  immediately  beneath  the 
enamel.  Portions  of  the  dentine  imperfectly  pro- 
tected by  the  enamel,  on  account  either  of  an  injured 


CARIES    OF   THE   TEETH.  45 

condition  or  of  an  imperfect  formation  of  the  latter, 
are  liable  to  be  attacked  by  this  disease  ;  and  points 
that,  by  their  location  or  any  other  unfavorable  cir- 
cumstance, retain  injurious  agents  in  contact  with 
the  tooth,  are  very  subject  to  decay. 

The  attack  and  progress  of  caries  are  modified  by 
the  constitution  of  the  teeth.  These  may  be  defec- 
tive, either  originally  or  accidentally.  Original  de- 
fectiveness extends  to  all  the  teeth  of  the  same 
individual,  whilst  accidental  exists  only  as  to  some 
of  the  teeth  in  the  same  mouth,  and  these  only  at 
particular  points.  Such  conditions  are  peculiarly 
favorable  for  the  attack  of  caries.  When  the  whole 
crown  of  the  tooth  is  imperfectly  organized,  the  decay 
will  progress  with  uniform  rapidity,  under  the  influ- 
ence of  uniformly  persistent  agents,  till  the  whole  is 
destroyed.  But  when  it  is  only  a  portion  of  the 
tooth,  the  caries  after  a  time  becomes  retarded  in  its 
progress,  and  in  some  cases  checked  altogether. 

Among  the  circumstances  which  modify  the  prog- 
of  this  disease,  are,  a  change  of  the  condition  or 
character  of  the  agencies  producing  it,  and  an  in- 
crease or  diminution  of  the  amount  of  such  agencies. 
The  progress  of  caries  will  also  be  governed  somewhat 
by  the  age  of  the  person  whose  teeth  it  attacks,  as 
well  as  by  the  peculiar  constitution  of  the  organs 
themselves;  for,  in  regard  to  constitution,  they  pre- 
sent   iin    almost  infinite  variety,  the   relative  proper- 


46  C1ABIES   OF   THE   TEETH. 

tions  of  their  constituents  being  exceedingly  various, 
even  in  persons  of  the  same  age,  and  continually 
varying  in  the  same  person  at  different  ages.  There 
is  a  constant  change  going  on,  the  calcareous  elements 
usually  increasing,  and  the  animal  decreasing.  But 
a  proper  relative  amount  of  elements  may  be  elab- 
orated, and  yet  a  defective  organization  exist.  This 
condition  arises  from  defective  organizing  power,  or 
from  a  failure  in  arrangement  and  combination  of 
the  materials,  and  is  dependent  entirely  on  accidental 
causes.  In  vital  energy,  indeed,  the  teeth  exhibit 
great  diversity ;  and  this  corresponds  with,  and  to 
some  extent  depends  upon,  the  vital  energy  of  the 
general  constitution.  Dead  dentine  is  decomposed 
more  readily  than  living;  and  hence  the  conclusion 
that  vitality  resists  caries,  and  that  this  resistance 
corresponds  with  the  vigor  of  the  vitality. 

The  points  most  frequently  attacked  by  caries  are 
the  proximate  surfaces  of  the  teeth,  the  indentations 
and  fissures  on  the  masticating  surfaces  of  the  molars 
and  bicuspids,  the  longitudinal  depressions  on  the 
buccal  and  palatal  walls  of  the  molars,  and  the  necks 
of  the  teeth  at  the  termination  of  the  enamel.  On 
the  proximate  surfaces,  the  enamel  is  thinner  than 
elsewhere;  and  the  situation  is  peculiarly  favorable 
for  the  accumulation  and  retention  of  injurious 
agents.  The  union  of  the  enamel  in  the  fissures  and 
indentations  of  the  crowns  of  the  molars  is  often  im- 


CARIES   OF    THE   TEETH.  47 

perfect;  and  thus  there  is  a  way  of  entrance  for 
vitiated  fluids  to  the  dentine.  Decay  is  found  at  the 
termination  or  intersections  of  these  fissures  earlier 
than  at  any  intermediate  points.  The  indentations, 
or  grooves,  on  the  sides  of  the  teeth  are  usually  at- 
tacked by  caries  at  that  point  next  to  the  neck.  Less 
frequently,  the  disorder  is  exhibited  at  the  neck,  just 
beneath  the  border  of  the  enamel,  under  which  it 
burrows  with  a  transverse  extension. 

The  order  in  which  the  elements  are  removed  is 
governed  by  the  nature  of  the  agent  which  effects 
the  decomposition;  and  this  is  usually  one  having 
an  affinity  for  the  calcareous  elements  strong  enough 
to  destroy  the  texture  of  the  dentine,  and  remove 
the  earthy  portion.  Those  acids  which  have  an 
affinity  for  the  lime  of  the  dentine,  produce  its  de- 
composition in  this  manner.  When  the  decay  is 
thus  caused,  the  portion  remaining  in  the  cavity  is 
soft,  and  approximates  the  gelatinous  condition  as 
the  calcareous  material  is  abstracted.  Agents  of  a 
different  character,  too,  often  produce  decay.  Alka- 
lies will  act  upon  the  animal  portion  of  the  dentine, 
and  remove  it;  and  in  caries  thus  produced,  the 
residue  is  friable  and  chalk-likr. 

In  other  cases  the  constituents  are  simultaneously 
removed.  Nitric  acid  will  cause  an  entire  break  ing- 
up  of  both  the  earthy  and  the  animal  constituents. 

The  dentine  outside  of  the  decay  may  be  in  an 


48  CARIES    OF    THE    TEETH. 

inflamed  and  irritable  condit":  that  the  contact 

.1  instrument  with  the  decayed  portion  will  pro- 
duce pain  :   and    thus  we  may  be  led  falsely  to  con- 
clude that  the    softened    dentine     -        asitive,  and, 
indeed,  it  is  maintained  that  in  some  cases  the  par- 
tially deco.i       -       dentine  is  so.  on   the  supposition 
that  a  -mall  portion  of  the  calcareous  elements  may 
emoved  and   vet  the  vitality  of  the   part  not  be 
roved. 
The      cogress  of  cari  r  more   rapid  in   the 

crowns  of  the  teeth  than  in  the  roots,  for  the  reason 
that  the  former  are  more  exposed    to  the   innu<  : 

rnal  injuries.     It  is  true  that  the  crowns  are 
red  by  enamel,  which   is  designed  to  shield  the 
dentine  from  injury,  but  this  is  often  defective,  and 
on   it   are   accumulated  agents  that  it  cannot  ] 

it  is  peri     t,  so  that   the  enamel  itself  is 
Lecomposed.     The  roots  receive  nourish- 
ment from  without   as  well   as  from  within,  and   be- 
cause of  th: _  gree  of  vitality  than 

.  and  their  ability  to  resist  the  encroach- 

_  eater,  and  hence 
jften  find  the    I  1  and  free  from 

decay  t:  >f  which   have   been  removed  by- 

rapid  decomposition.     Injurious  substanc  une- 

times  -d  into  contact  with  the  dentine   through 

defects  in  the  enamel,  or  under  its  projections,  and 


CARIES    OF    THE    TEETH.  49 

there    retained    till  their  niischievou-  t  if   pro- 

duced. 

It  is  maintained  by  some  wri  -  is  con- 

Dr.    Koecker   was   or    this   opinion. 
-non.  then.  is.  whether  thei       -    .uiy  property  in 
the  decayed  dentine  of  one  tooth  capable  of  produc- 

_  the  same  condition  in  the  healthy  dentine  of  an- 
The  residue  of  dental  decay  consists    I  the 

_  . uic  or  animal  constituents  and  a  small  portion  of 
earthy  material,  and  in   decay,  in  which   the    g 
nous  constituent  is  abstract  remainder  is  chalk- 

like,       tsisting   mainly  of   phosphate  of  lime.     In 
neither  o^l  these  is  there  anything  that  can  [    — 
operate  on  the  healthy  dentine.     There  is  one  thing 
here,  however,  that  is  worthy  of  remark,  and  that 
perhaps  led  to   the   mistaken   notion  that   c 
cont   _       9     decayed  dentiue  will  absorb  and  retain 
fluids  that  injuriously  affect  sound  dentine,  and  when 
the  decay  is  on  the  proximate  portion  two  teeth  are 
subject  to  the  same  exciting  cause.     But  it  is  seldom 
that   two   teeth   thus  situated  are  both  in  the  same 
-     _  decay — a  tact  principally  attribu:  the 

difference  in  their  constitution        sus  eptibility.  The 
decay  of  the  teeth  in  pairs  has  also  been  adduce 

the  contagious  character  of  the 
This.  li.  dtfl  from  the   fact  that  the   g 

are  funned  at  t'.      b  time,  are  subject  to  the  same 

influences  in  their  formation,  and  hence  are  eo: 

4 


50  CARIES   OF   THE   TEETH. 

tutecl  alike,  and  if  one  of  the  pair  is  defective,  the 
other  will  probably  be  in  a  like  condition.  When 
there  is  a  vitiation  of  the  saliva  or  mucus  they  will 
be  similarly  affected.  In  no  common  acceptation  of 
the  term  contagious  can  it  be  applied  to  caries  of  the 
teeth. 

The  color  of  caries  is  exceedingly  various,  from 
that  of  healthy  dentine,  through  every  intermediate 
shade,  to  jet  black.  The  rate  of  the  progress  is  in- 
dicated by  the  color  of  the  decay,  being  slower  as  it  is 
darker,  so  that  when  the  decay  becomes  almost  sta- 
tionary, the  affected  portion  is  usually  black.  The 
degrees  of  color  are  differently  enumerated  by  different 
writers,  as,  by  Koecker,  five,  by  others,  seven,  and 
so  on.  Three,  however,  are  sufficient  for  our  purpose  : 
white,  brown,  and  black.  The  sensitiveness  of  the 
dentine  is  greatest  in  teeth  affected  by  the  white  de- 
cay, and  usually  decreases  as  the  color  darkens ; 
though  there  are  exceptions  to  this  rule,  for  occa- 
sionally the  teeth  affected  by  dark  decay  are  quite 
sensitive.  The  light-colored  decay  is  more  difficult 
to  arrest  than  the  dark.  In  many  cases  of  the  former 
filling  seems  hardly  to  retard  its  progress;  whereas, 
in  the  latter,  by  proper  filling,  the  advance  of  the 
decay  may  be  checked  altogether.  The  cause  of  the 
dark  color  of  caries  is  mainly  due  to  the  carboniza- 
tion of  the  animal  portion. 

The  dark,  and  especially  the  black  variety  of  decay 


CARIES    OF   THE    TEETH.  51 

is  much  less  rapid  in  its  progress  than  the  light,  brown 
or  white  variety,  and  chiefly  because  the  debris  or  re- 
siduum is  insoluble,  and  much  less  disintegrated  than 
in  the  other  varieties,  the  animal  part  being  retained 
in  a  carbonized  state,  and  the  calcareous  constituent 
to  a  considerable  extent  retained,  and  in  a  form  not 
soluble  in  the  fluids  of  the  mouth. 

Thus  a  far  better  protection  to  the  dentine  beneath 
is  present  in  the  black  than  in  any  other  variety  of 
decay. 

Some  sensitiveness  commonly  accompanies  caries. 
It  does  not  often  amount  to  pain,  but  is  rather  a 
sense  of  uneasiness ;  yet,  from  change  of  tempera- 
ture, or  contact  of  acids  or  hard  substances,  intense 
pain  may  be  produced.  Dr.  Koecker  remarks  that 
caries  is  most  tender  in  its  first  stages ;  and  Dr. 
Cone  that  when  a  tooth  is  .attacked  by  it  the  sensi- 
tiveness is  increased.  The  surface  of  the  dentine  is 
susceptible  of  the  most  acute  sensitiveness.  When 
there  is  inflammation  of  the  dentine,  intense  pain 
may  be  produced  by  the  contact  of  an  instrument 
in  a  cavity  of  decay,  at  the  line  of  union  of  the  den- 
tine with  the  enamel,  with  very  little  sensitive: 
present  elsewhere  in  the  cavity.  Sensitiveness  of  a 
uniform  character  sometimes  pervades  all  parts  of 
the  cavity,  while  at  other  times  it  may  be  very  in- 
tense at  one  point,  and  very  slight  or  entirely  absent 
at  any  other.     A  thin  lamina  of  the  dentine  lining 


52  CARIES   OF   THE   TEETH. 

the  whole  cavity  may  be  uniformly  sensitive,  and  in 
some  cases  sensitiveness  involves  the  entire  body  of 
the  dentine. 

By  means  of  this  sensitiveness;  warning  is  trans- 
mitted to  the  pulp,  which  emits  calcareous  material 
with  increased  energy;  and  thus  a  process  of  filling 
up  the  natural  cavity  of  the  tooth  is  instituted,  that 
the  decay  may  not  encroach  upon  the  pulp.  But  this 
warning  may  in  some  degree  be  transmitted  to  the 
pulp  though  there  be  no  appreciable  increase  of  sen- 
sitiveness. 

This  sensitiveness  is  modified  by  the  character  of 
the  teeth,  the  nature  of  the  decay,  and  the  state  of 
the  patient's  system.  The  teeth  of  the  same  person 
will  be  more  sensitive  at  one  time  than  at  another, 
because  of  a  greater  irritability  of  the  nervous  system. 
Those  teeth  which  decay  most  rapidly  are  usually 
most  sensitive  ;  though  in  teeth  whose  vitality  is  lost 
considerably  in  advance  of  their  decay,  there  is  no 
perceptible  sensitiveness  present.  Except  in  such 
cases  as  last  mentioned,  the  whitest  and  most  rapid 
decay  has  most  sensitiveness,  the  brown  much  less, 
and  the  black  scarcely  any. 

Predisposing  Causes  of  Caries. 

The  causes  of  caries  of  the  teeth  may  be  considered 
under  two  general  divisions — predisposing  and  excit- 


PREDISPOSING   CAUSES   OF   CARIES.  53 

ing.  Of  the  former  some  are  original,  others  acci- 
dental. The  original  development  of  the  constitution 
may  be  defective,  either  from  original  or  from  acci- 
dental defect  in  the  parent,  but  more  certainly  from 
the  former.  Constitutional  characteristics  are  trans- 
missible, and  a  defect  is  as  surely  hereditary  as  any- 
thing else.  In  the  foetus,  during  gestation,  germs 
may  have  originated  from  which  perfect  organs  can 
never  be  developed,  and  these  germs  may  be  more  or 
less  defective  according  to  the  constitutional  condition 
of  the  mother,  or  according  to  accidental  conditions  to 
which  she  may  be  subject,  and  which  may  seriously 
affect  the  foetus.  After  birth,  too,  the  child  is  exposed 
to  injurious  impressions,  which  will,  to  a  greater  or 
less  degree,  render  the  development  defective ;  as 
imperfect  nourishment  and  the  diseases  and  func- 
tional derangements  peculiar  to  childhood.  A  dis- 
eased condition,  or  functional  derangement,  will 
interrupt  the  proper  elimination  and  perfect  upbuild- 
ing of  the  materials  necessary  for  the  perfect  struc- 
ture ;  and  indeed  anything  that  will  disturb  the 
equilibrium  of  action  in  the  system  may  be  detri- 
mental to  the  teeth. 

In  some  instances  the  teeth  will  exhibit  the  pecu- 
liarities of  the  mother,  and  in  others  those  of  the 
father,  while  sometimes  they  simulate  those  of  both 
parents  ;  and  when  the  parental  imprint  is  thus  found 
aped  on  tli<-  teeth,  it  will  also  !><'  found  that  those 


54  CARIES   OF   THE   TEETH. 

of  the  same  class  decay  at  the  same  points  and  at 
about  the  same  age  as  in  the  parent.  In  such  cases 
the  defect  is  manifestly  hereditary ;  it  cannot  be  ac- 
cidental :  the  coincidences  thus  constantly  occurring 
preclude  any  other  conclusion.  Hereditary  taint, 
then,  may  be  regarded  as  a  predisposing  cause  of 
caries. 

Impaired  vitality  is  another  predisposing  cause ; 
and  not  only  impaired  vitality  of  the  teeth  and  con- 
tiguous parts,  but  also  that  of  the  general  system. 
Indeed,  the  vital  vigor  of  the  teeth  depends  upon 
that  of  the  general  system,  and,  when  there  is  no 
local  adverse  influence  at  work,  corresponds  with  it; 
so  that  when  the  general  system  is  in  the  most 
healthy  condition,  the  teeth  possess  the  greatest 
power  of  resistance  to  deleterious  agencies.  This  re- 
sisting power  is,  at  best,  comparatively  feeble ;  but 
its  feebleness  is  to  some  extent  compensated  by  the 
peculiar  structure  of  the  teeth,  which  are  less  liable 
to  decomposition  than  any  other  part  of  the  human 
body.  Yet  the  integrity  of  these  organs  depends 
much  on  the  maintenance  of  a  healthy  vitality,  and 
this  on  that  of  the  general  system.  A  dead  tooth 
will  decay  far  more  rapidly  than  a  living  one  in  simi- 
lar circumstances ;  and  hence  the  conclusion  that 
vitality  resists  injurious  agents,  and  that  the  resist- 
ance will  be  in  proportion  to  the  vigor  of  the  vitality. 

All  febrile  conditions  promote  and  facilitate  decay, 


PREDISPOSING   CAUSES   OF   CARIES.  55 

and  frequently  in  two  ways  :  by  diminishing  vitality, 
and  by  changing  the  secretions  of  the  mouth  so  that 
these  act,  either  directly  or  indirectly,  injuriously 
upon  the  teeth.  Accompanying  such  conditions  there 
is  generally  inflammation  of  the  dentine ;  and  in  such 
cases  this  always  partakes  of  the  general  disorder,  so 
as  to  become  very  susceptible  to  injury.  All  diseases, 
indeed,  that  impair  the  vitality  and  change  the  secre- 
tions, may  be  considered  predisposing  causes  of  decay, 
and  some  even  more ;  dyspepsia,  for  instance,  being 
not  only  predisposing,  but  also  exciting,  since  it  pre- 
pares in  the  stomach  an  acid  that  is  almost  contin- 
ually thrown  upon  the  teeth,  and  that  acts  upon  them 
with  great  energy.  Residence  in  miasmatic  regions  is 
also  a  predisposing  cause,  inducing  unfavorable  con- 
ditions. 

Diminished  vitality  may  result  either  from  systemic 
or  from  local  causes.  These  latter  are  such  as  pro- 
duce an  irritable  or  diseased  condition  of  the  con- 
tiguous parts,  or  an  abnormal  condition  of  the  den- 
tine, without  the  power  to  effect  its  decomposition. 
Local  causes  of  a  diminution  of  vitality  are  not  in 
their  character  so  formidable,  and  not  so  difficult  to 
control,  as  those  which  are  constitutional. 

Many  medical  agents  are  regarded  as  predisposing 
causes  of  caries,  and  among  these  mercurials  occupy 
a  prominent  place.  They  operate  by  vitiating  the 
secretions  of  the  mouth,  and  producing  an  abnormal 


56  CARIES    OF   THE   TEETH. 

condition  of  the  periosteum  about  the  roots  of  teeth, 
the  mucous  follicles  and  the  salivary  glands.  Some 
entertain  the  opinion  that  the  abnormal  action  of 
the  absorbents  induced  by  mercurials  predisposes  to 
decay. 

Dental  operations  performed  at  an  improper  time, 
and  in  an  improper  manner,  may  be  reckoned  among 
the  predisposing  causes  of  caries.  The  vitality  of 
the  teeth  may  be  thus  impaired,  or  a  diseased  condi- 
tion established,  or  the  part  operated  upon  may  be 
permitted  to  remain  rough,  so  that  foreign  substances 
will  be  retained,  and,  becoming  vitiated,  produce  a 
deleterious  effect.  Often,  from  an  improper  use  of 
the  file,  extensive  inflammation  of  the  dentine  super- 
venes, which  is  sometimes  followed  by  death  of  the 
tooth,  and  by  disease  of  the  contiguous  parts.  Arti- 
ficial substitutes,  imperfectly  adapted,  are  in  many 
instances  the  occasion  of  caries;  not  that  clasps  or 
the  edges  of  the  plate  tend  directly  to  injure  the 
teeth,  but  the  agencies  superinduced  by  them  do, 
and  especially  when  the  material  used  is  not  of  the 
right  quality. 

Lack  of  proper  exercise  in  mastication  induces  a 
condition  favorable  to  decay,  both  by  favoring  the 
action  of  injurious  agents  upon  the  teeth,  and  by  with- 
holding the  stimulus  of  normal  exercise.  Calculus 
and  other  deleterious  substances  are  much  more 
rapidly  deposited  when  the  teeth  are  idle. 


EXCITING   CAUSES   OF   CAIUE9.  57 

The  teeth  cannot  with  impunity  undergo  great 
and  sudden  transitions  of  temperature,  or  even  such 
variations  as  may  be  endured  by  the  surrounding 
parts.  By  these,  inflammation  of  the  dentine  may 
be  induced,  and  the  vitality  of  the  teeth  dimin- 
ished. And  in  friable  teeth,  checking  of  the  enamel 
ma}7  occur,  and  thus  a  condition  arise  that  will  pro- 
mote decay. 

Exciting  Causes  of  Caries. 

When  there  is  a  predisposition  to  caries,  any  of 
the  exciting  causes  act  with  more  effect.  Well-organ- 
ized teeth,  of  unimpaired  health  and  vitality,  with- 
stand influences  that  in  less  favorable  circumstances 
destroy  them  in  a  very  short  time.  The  immediate 
cause  of  decay  is  the  action  of  agents  chemically 
upon  the  teeth.  It  is  not  here  proposed  to  enter 
upon  an  investigation  of  the  manner  in  which  these 
various  agents  operate,  for  that  would  open  up  a 
large  field  for  consideration — a  field  outside  of  the 
province  of  this  work.  The  sources  of  these,  how- 
ever, are  several :  as,  vitiated  secretions  of  the  mouth; 
the  saliva  and  the  mucus;  abnormal  secretion  from 
the  stomach  ;  decomposition  of  animal  and  vegetable 
substances  in  the  mouth,  etc. 

The  natural  state  of  the  mucus  is  acid,  hut  that 
of  the  saliva  alkaline,  and  under  proper  balance 
the-  mixed  fluid  is  neutral;    hut  when   the  saliva  and 


58  CARIES   OF   THE   TEETH. 

the  mucus  are  both  acid,  the  teeth  must  suffer.  These 
secretions  may  become  vitiated  through  inability  of 
the  glands,  from  disease  or  an  enfeebled  condition, 
perfectly  to  perform  their  functions  ;  or  the  blood 
may  be  in  an  abnormal  state,  and  the  glands  unable, 
on  that  account,  though  they  were  healthy, — as  they 
seldom  are  in  such  case, — to  elaborate  healthy  saliva. 
When  the  fountain  is  corrupt  the  stream  cannot  be 
pure.  Thus  some  things,  at  least,  that  produce  a  dis- 
eased condition  of  the  blood  tend  to  the  decay  of  the 
teeth ;  and  such  diseased  condition  often  has  a  di- 
rectly injurious  effect  on  the  secretive  apparatus,  and 
so  works  a  double  harm. 

But  to  the  theory  of  the  pernicious  influence  of 
the  saliva  it  may  be  objected,  that,  if  it  were  true,  all 
parts  of  the  teeth  would  be  alike  affected.  This  ob- 
jection, however,  will  lose  its  force  when  it  is  con- 
sidered that  the  teeth,  in  many  cases,  are  not  equally 
well-organized  in  all  their  parts,  some  much  more 
vulnerable  than  others;  that  some  parts  are  not  so 
well  protected  as  others;  and  that  between  the 
teeth  there  is  room  for  the  retention  of  saliva  and 
foreign  substances,  which  there  combine  their  influ- 
ence upon  them.  When  there  is  a  great  quantity  of 
viscid  saliva  constantly  flowing,  the  teeth  decay  very 
rapidly.  The  decay  is  of  a  light  color,  so  light,  in- 
deed, that  in  many  instances  it  is  difficult  to  dis- 
tinguish it,  by  this,  from  undecomposed  dentine.' 


EXCITING  CAUSES   OF   CARIES.  59 

The  gastric  fluid  often  becomes  deranged  by  irri- 
tation or  disease  of  the  stomach,  so  that  the  function 
of  the  latter  is  very  imperfectly  performed,  and  fer- 
mentation of  the  food  occurs,  evolving  agents  that 
injuriously  affect  the  teeth.  In  dyspepsia,  such 
agents  are  often  brought  in  contact  with  the  teeth 
by  eructation  and  vomiting,  and  the  diseased  gastric 
fluid,  which  contains  hydrochloric  acid,  is  also  thus 
brought  in  contact  with  them,  acting  with  great 
energy.  After  food  commingled  with  this  secretion 
is  ejected  from  the  stomach,  the  teeth  will  be  found 
corroded  over  all  their  surfaces.  Dyspeptics  will  ap- 
preciate this  remark.  In  such  cases,  if  the  teeth  are 
not  of  superior  organization,  they  are  destroyed  in  a 
short  time.  Their  surfaces,  thus  roughened,  afford  a 
lodgment  for  foreign  substances  on  all  parts. 

The  most  common  agents,  however,  that  injure  the 
teeth,  are  originated  in  the  mouth  by  the  decompo- 
sition of  animal  and  vegetable  matter.  By  this 
process,  elements  are  eliminated  that  form  new  com- 
binations, and  these  operate  with  energy  in  the 
destruction  of  the  teeth.  Favorable  conditions  exist 
in  the  mouth  for  such  decomposition,  and  also  for 
such  new  combinations;  for  there  is  a  sufficient 
amount  of  heat  and  moisture, — for  both  of  these, 
especially  the  former,  facilitate  the  action  of  any  acid 
upon  the  dentine.  The  character  of  the  saliva  and 
mucus  will  very  much  modify  the  decomposition  of 


60  CARIES    OF    THE   TEETH. 

foreign  substances  in  the  mouth.  If  these  secretions 
are  both  acid,  the  decomposition  will  be  much  more 
rapid,  and  more  potent  in  its  effect. 

Again,  it  is  sometimes  the  case  that  the  salivary 
glands  are  comparatively  inactive,  except  when  spe- 
cialty excited,  and  yet  the  mucous  glands  still  effi- 
cient, eliminating  their  secretion ;  so  that  the  mouth 
assumes  an  acid  condition,  because  there  is  not  saliva 
sufficient  to  neutralize  the  mucus,  in  which  condition 
decomposition  of  foreign  substances  would  be  greatly 
accelerated.  There  are  many  cases,  however,  in 
which  the  flow  of  saliva  is  copious,  and  yet  the  decay 
rapid,  which  is  in  consequence  of  an  acid  condition 
of  both  secretions,  or  of  a  speedy  decomposition  of 
foreign  substances  in  the  mouth. 

There  are  acids  taken  with  the  food  that  act 
directly  upon  the  teeth  ;  as  acetic  acid,  or  vinegar. 
It  has  generally  been  supposed  that  acids  taken  with 
the  food  act  directty  upon  the  teeth. 

Professor  Westcot  says :  "  Acetic  and  citric  acids 
so  corroded  the  enamel  in  forty-eight  hours,  that 
much  of  it  was  •easily  removed  with  the  finger  nail, 
and  malic  acid  or  the  acid  of  apples,  in  its  concen- 
trated state,  also  acts  promptly  upon  the  teeth." 
These  acids,  in  the  use  of  many  kinds  of  food,  are 
brought  into  frequent  contact  with  the  teeth. 

But  these  and  similar  acids,  however  freely  they 
maj7  be  used,  exercise  no  direct  influence  in  the  pro- 


EXC1TIXG    CAUSES   OF   CARIES.  61 

duction  of  the  common  dental  decay.  But  these  and 
such  acids  do  play  an  important  part  indirectly  in 
the  erosion  and  roughening  which  they  produce  upon 
the  surfaces  of  the  teeth,  with  which  they  are  brought 
fully  in  contact,  thus  making  vulnerable  points  of 
attack  for  the  acting  agents  of  decay. 

Another  way  in  which  these  common  acids  act 
indirectly  is  by  promoting  the  decomposition  of  sub- 
stances from  which  arise  the  .agents  that  do  effect 
decay  of  the  teeth. 

In  the  manufacture  of  vinegar,  sulphuric  acid  is 
often  employed  ;  so  that  in  this  article  of  food  we 
have  that  acid  either  alone  or  combined  with  the 
acetic,  the  former  acting  with  greater  energy  upon 
the  teeth  than  the  latter.  Acetic  acid  also  facilitates 
the  fermentation  of  food  retained  in  the  mouth,  and 
thus  reproduces  itself  in  abundance. 

After  eating  apples  that  contain  a  large  amount  of 
malic  acid,  the  teeth  will  be  found  corroded  over  all 
their  surfaces.  This  acid,  as  well  as  the  others, 
affects  the  enamel  somewhat,  and  when  the  latter  is 
very  thin,  though  it  may  not  be  all  removed  from 
any  particular  point,  yet  its  integrity  will  be  de- 
stroyed, so  as  to  be  readily  fractured,  thus  admitting 
injurious  agents  to  contact  with  the  dentine,  which 
ie  much  more  susceptible  of  injury  from  acids  than 
the  enamel  :  points  imperfectly  protected  by  this  are 
violently   attacked   by   acetic,  malic,   and   sulphuric 


62  CAKIES   OF   THE   TEETH. 

acids,  especially  when  in  the  nascent  state.  In 
decayed  cavities  these  agents  produce  rapid  results. 
They  should  be  as  much  as  possible  avoided,  and, 
when  necessarily  used,  should  be  removed  from  the 
teeth  by  cleaning  with  great  care.  It  would  be  safest 
to  employ  some  neutralizing  agent  after  the  use  of 
any  acids  with  food.  During  mastication,  there  is  an 
increased  secretion  of  saliva,  which,  if  in  a  healthy 
state,  will  tend  to  neutralize  any  acid  that  may  at 
the  time  be  present,  and  also,  by  its  flow,  to  remove 
foreign  substances  from  the  mouth. 

Some  acids  combined  with  metallic  or  alkaline 
bases,  are  used  as  medicines,  some  of  them  are  easily 
decomposed,  when  the  newly  liberated  acid  will  act 
with  energy  upon  the  teeth ;  but  even  this  does  not 
produce  the  ordinary  decay,  acting  only  upon  the 
surfaces  of  the  teeth,  whenever  it  may  come  in  con- 
tact with  them. 

Many  medical  preparations  contain  agents  pecu- 
liarly deleterious  to  the  teeth,  acids  being  especially 
in  requisition  for  these,  and  oftentimes  in  considera- 
ble quantities.  The  acids  most  commonly  thus  ad- 
ministered are  the  hydrochloric,  the  nitric,  the  sul- 
phuric, the  acetic,  the  tartaric,  and  the  citric,  any 
one  of  which  will  produce  direct  and  rapid  corrosion 
of  the  dentine,  even  when  unaided  by  the  temperature 
of  the  mouth.  For  a  fuller  and  more  explicit  pres- 
entation of  the    points    here   briefly  hinted   at.  see 


EXCITING    CAUSES   OF   CARIES.  63 

Appendix  at  the  close  of  this  volume,  Sec.  A.  These 
acids  are  often  administered  by  physicians  without 
any  regard  to  their  nature  or  their  influence  upon  the 
teeth.  Sometimes,  however,  they  are  given  through 
a  tube,  though  this  method  generally  does  not  amount 
to  much  as  a  precautionary  measure,  for  in  most  in- 
stances the  fluid  comes  in  contact  with  all  parts  of 
the  mouth.  A  subsequent  rinsing  of  the  mouth  with 
water  effects  only  a  dilution,  not  an  entire  removal 
of  the  acid.  In  order  wholly  to  counteract  their  in- 
jurious influence  upon  the  teeth,  an  alkaline  solution 
should  be  used  after  the  administration  of  such 
medicines. 

Galvanic  action  is  a  cause  of  decay  of  the  teeth, 
only  so  far  as  it  is  a  means  of  decomposing  com- 
pounds in  the  mouth,  and  the  elements  of  which, 
according  to  the  laws  of  affinity,  form  other  com- 
pounds prejudical  to  the  teeth.  The  elements  hy- 
drogen, nitrogen,  and  oxygen,  may  thus  be  set  free 
from  animal  and  vegetable  substances,  when  they  will 
at  once  seek  other  elements  with  which  to  combine; 
and  the  character  of  the  combinations  will  be  deter- 
mined by  the  nature  of  the  elements,  and  by  the 
attendant  circumstances.  These  compounds  will  fre- 
quently be  of  an  acid  character,  or  contain  acid. 

Such  an  arrangement  may  exist  as  will  maintain 
a  constant  galvanic  action,  whose  legitimate  effects 
will  be  ae  constant  upon  the  teeth;  and  this  cease- 


64  CARIES   OF   THE   TEETH. 

less  process  cannot  but  make  its  mark.  It  is  a 
favorable  arrangement  for  galvanic  action  when  there 
are  two  or  three  kinds  of  metals  in  the  mouth  ;it 
once,  particularly  if  these  are  such  as  differ  in  their 
affinities  for  oxygen,  and  in  their  electric  conditions. 
In  some  cases  three  or  four  kinds  of  metals  are 
employed  in  filling  teeth  of  the  same  mouth ;  in 
some,  fillings  of  one  metal  and  a  plate  of  another; 
and  in  others,  plates  of  so  low  a  carat  are  used  that 
they  oxidize  rapidly  in  the  mouth  without  the  aid 
of  any  other  metal. 


Comparative  Liability  to  Decay. 

All  classes  of  teeth  are  not  alike  liable  to  deca^ 
Their  difference  in  this  respect  may  arise  from  a 
dissimilarity  in  their  organic  structure,  the  best  or- 
ganized being  the  most  capable  of  resisting  disease ; 
or  from  a  concentration  of  the  destructive  agency 
upon  the  tooth  first  affected.  The  first  molars  are 
much  more  liable  to  decay  than  any  other  teeth, 
since  they  are  less  perfectly  developed  than  those 
formed  at  a  later  period  of  life.  They  are  the  first 
permanent  teeth  erupted,  and  are  subjected  to  all 
the  irritating  conditions  consequent  on  the  removal 
of  the  temporary,  and  the  development  and  eruption 
of  the  permanent  teeth.  But  these  conditions  in 
many  cases  produce  no  apparent  injury  upon  them, 


COMPARATIVE    LIABILITY   TO    DECAY.  65 

they  maintaining  their  integrity  till  all  the  other 
permanent  teeth  appear,  and  then  decaying  earlier 
than  any  others.  In  such  cases,  the  decay  is  a  result 
of  influences  more  potent  than  those  occurring  on  the 
eruption  of  the  other  teeth. 

After  the  first,  the  second  molars  are  most  subject 
to  caries,  and  after  these  the  second  bicuspids.  The 
latter  two  classes,  doubtless,  are  so  subject  more 
from  the  facility  they  afford  to  the  lodgment  of  dele- 
terious substances  than  from  a  relatively  imperfect 
organization.  Besides,  from  six  to  fifteen  years  of 
age  the  teeth  are  less  appreciated  and  less  cared  for 
than  at  a  later  period  of  life.  The  next  most  liable  to 
decay,  are  the  third  molars.  Then  follow  in  order  the 
first  bicuspids,  the  lateral  incisors,  the  central  incis- 
ors, and  the  cuspids.  Herewith  are  appended  in  tabu- 
lar form  nearly  one  thousand  cases  of  decayed  teeth, 
as  observed  under  ordinary  circumstances,  exhibiting 
the  number  and  per  cent,  of  these  in  each  class : 

26,  or    2\  per  cent.,  in  central  incisors. 

28,  or    2|  "  in  lateral  incisors. 

24,  or     2\  "  in  cuspids. 

87,  or     8f  in  first  bicuspids, 

134,  or  13|  "  in  second  bicuspids. 

370,  or  '.'>'  in  first  molars. 

218,  or  22|  "  in  second  molars. 

102,  or  10J  "  in  third  molars. 

Of  these,  a  large  proportion  were  removed  for  re- 
lief from   disease  originating  in  caries  of  the  dental 


66  CARIES   OF   Till;   TEETH. 

tissue.     In  general,  the   superior  teeth  are  liable  to 
decay  earlier  and  more  rapidly  than  the  inferior. 

Consequences  of  Caries. 

It  is  here  proposed  to  refer  only  to  some  of  the 
more  common  results  of  this  affection.  One  of  the 
most  obvious  of  which  is  the  exposure  of  the  pulp 
of  the  tooth,  on  which  exposure  disease  ensues,  and 
finally  death.  During  this  diseased  condition  of  the 
pulp  there  occurs  that  very  peculiar  and  well-known 
sensation  commonly  denominated  toothache.  As  well 
as  the  destruction  of  the  pulp,  the  entire  destruction 
of  the  crown  of  the  tooth  is  the  inevitable  conse- 
quence of  caries,  unless  arrested  in  its  progress.  After 
the  destruction  of  the  pulp  and  the  lining  membrane, 
the  external  periosteum  in  many  cases  becomes  in- 
volved, the  affection  being  but  an  extension  of  that 
which  destroys  the  internal  periosteum.  Inflamma- 
tion and  suppuration  are  of  common  occurrence,  by 
which  a  discharge  is  established  from  between  the 
margin  of  the  gum  and  the  neck  of  the  tooth,  or 
through  a  fistulous  opening  in  the  process  and  the 
gum,  as  is  the  case  when  an  abscess  is  formed  at  the 
point  of  the  root. 

A  diseased  condition  of  the  alveolar  process  is  in 
many  instances  produced  by  diseased  and  dead 
teeth,  necrosis  and  exfoliation  of  considerable  portions 


CONSEQUENCES   OF    CARIES.  67 

being  sometimes  the  result,  Indeed,  extensive  caries 
of  the  jaw  is  occasionally  thus  produced.  Disease 
of  the  antrum,  too,  is  very  generally  induced  or 
greatly  aggravated  by  the  same  cause.  Tumors, 
sometimes  of  a  malignant  character,  connected  either 
with  the  bony  or  with  the  soft  parts,  not  unfrequently 
spring  from  this  source,  particularly  in  constitutions 
of  a  cancerous  diathesis.  Great  nervous  derange- 
ment may  result,  either  in  whole  or  in  part,  from  de- 
cayed teeth,  as  does  very  frequently  facial  neuralgia, 
which  is  sometimes  confined  to  a  single  nerve-branch 
in  the  immediate  vicinity  of  the  irritating  cause, 
sometimes  ramified  over  the  whole  side  of  the  face 
and  head,  and  occasionally  spreads  much  farther,  so 
as  even  to  implicate  the  shoulder  and  the  arm.  Neu- 
ralgia of  these,  extending  down  to  the  hand,  is  often 
found  to  be  instantly  relieved  by  extraction  of  a  dis- 
eased tooth  ;  and  any  operator  of  much  observation 
can  call  to  mind  numerous  instances  in  which  facial 
neuralgia  has  been  thus  relieved  or  wholly  cured. 
This  affection  of  the  face,  however,  does  not  always 
originate  in  diseased  teeth,  though  there  is  little  doubt 
that  in  a  majority  of  cases  it  arises  wholly  or  partially 
from  this  cause. 

Inflammation  of  the  mucous  membrane  of  the 
mouth  is  a  common  result  of  diseased  teeth,  and  it 
is  liable  to  extend  to  distant  parts  of  this  mem- 
brane,   and    occasion    greater   difficulty    than   in    the 


68  CARIES    OF   THE    TEETH. 

mouth,  as  would  especially  be  the  case  when  there  is 
an  irritable  condition  of  the  throat  and  bronchia;  and 
the  oesophagus  and  stomach  are  not  exempt.  In  what 
degree  such  an  implication  of  the  respiratory  and 
the  digestive  apparatus  is  referable  to  diseased  teeth, 
it  may  not  be  easy  to  determine,  but  it  is  impossible 
that  a  number  of  such  teeth,  involving  in  their 
disease  all  the  ramifications  of  the  facial  nerves  and 
the  whole  mucous  membrane  of  the  mouth,  could 
remain  there  with  impunity.  And  besides  this  direct 
influence  on  the  lungs  and  stomach,  diseased  teeth 
are  constantly  emitting  offensive  odors,  which  are 
taken  in  by  inhalation,  and  offensive  matter  which 
is  swallowed  with  the  food. 

Treatment  of  Caries. 

In  the  rational  treatment  of  caries  the  first  con- 
siderations are  the  nature  and  peculiarities  of  the 
obvious  predisposing  causes  ;  whether  these  are  con- 
stitutional or  local,  and  if  constitutional,  whether 
they  are  such  as  can  be  modified  by  therapeutic 
treatment  of  the  general  system.  If  the  latter,  such 
treatment  should  be  adopted  as  will  bring  about  the 
most  perfect  state  of  health,  so  as  to  obviate  as  far 
as  possible  all  conditions  favorable  to  decay,  by  se- 
curing a  healthy  condition  of  the  mouth  in  all  its  parts 
— as  the  gums,  the  mucous  membrane,  and  the  sali- 


TREATMENT    OF   CARIES.  69 

vary  glands.  The  teeth  should  be  kept  free  from  all 
deposits  and  accumulations  of  whatever  character; 
for,  though  some  of  these  may  not  affect  the  teeth 
directly,  yet  they  induce  disease  of  the  surrounding 
parts,  and  thus  indirectly  exert  a  pernicious  influence 
upon  them. 

The  foregoing  remarks,  however,  refer  rather  to 
the  prevention  of  decay  than  to  its  treatment  after 
it  actually  exists.  Yet  they  are  on  that  account  none 
the  less  important,  since  here,  as  elsewhere,  preven- 
tion is  better  than  remedy.  But  they  apply  to  such 
prevention  as  well  after  decay  has  commenced  as  be- 
fore, if  the  ultimate  object  is  preservation  of  the  teeth. 
After  the  first  attack  the  teeth  are  more  vulnerable 
and  less  capable  of  resistance. 

When  decay  has  attacked  a  tooth,  the  treatment 
indicated  depends  upon  the  nature  and  extent  of  the 
disease.  Rapid  decay  requires  more  prompt  and 
energetic  treatment  than  that  of  slow  progress. 
Remedies  appropriate  and  efficient  in  the  one  are 
quite  inapplicable  to  the  other.  The  persistence  of 
caries  is  not  always  in  proportion  to  its  rate  of  prog- 
ress. We  sometimes  find  teeth  in  which  the  decay 
is  not  advancing  rapidly,  and  thence  are  led  to  con- 
clude that  it  may  be  easily  arrested ;  the  affected 
part,  if  superficial,  is  easily  removed,  and  the  dentine 
thoroughly  polished;  and  yet,  after  a  time,  decay 
again  attacks  the  tooth  at  the  same  point.     Or,  where 


70  CARIES   OF   THE  TEETH. 

the  caries  has  penetrated  the  tooth,  so  that  it  requires 
filling,  though  it  is  .skilfully  done,  and  the  plug  and 
tooth  carefully  polished,  yet  in  many  instances  the 
dentine  soon  softens  about  the  border  of  the  filling. 

The  extent  and  nature  of  the  decay  will  suggest 
the  mode  of  treatment.  Superficial  caries  on  some 
parts  of  the  teeth  may  be  remedied  and  removed  by 
cutting  away  the  portion  implicated  in  the  disease, 
dressing  with  a  fine  file,  polishing  with  Arkansas, 
Scotch,  or  rottenstone  till  the  file-marks  disappear, 
and  then  applying  the  buff  with  rouge  or  oxide  of  tin, 
very  thoroughly  to  the  entire  surface  operated  upon. 
Afterward,  the  most  careful  attention  to  cleanliness 
is  requisite,  to  prevent  a  recurrence  of  the  attack. 
This  treatment  is  applicable  to  decay  upon  proximate 
surfaces  ;  but  in  the  depressions  of  the  masticatory 
and  buccal  surfaces  of  the  molars,  it  is  not  practicable. 

Sometimes  the  dentine,  at  points  where  it  is  ex- 
posed, gives  warning,  by  acute  sensitiveness,  of  threat- 
ened decomposition,  before  there  are  any  other 
indications  of  it,  thus  evidencing  the  presence  of 
some  very  irritating  agent  promotive  of  decay.  Such 
points  should  receive  prompt  and  strict  attention, 
and  the  increased  sensitiveness  be  immediately  sub- 
dued ;  as  it  may  be  by  the  use  of  some  preparation 
that  will  counteract  the  exciting  influence — some 
dentifrice  or  lotion  containing  an  alkali ;  or  rubbing 
the  sensitive  surface  with  a  steel  burnisher  will  in 


TREATMENT   OF   CARIES.  71 

many  cases  effect  this  object,  and  prevent  the  devel- 
opment of  decay.  Nitrate  of  silver  is  sometimes  used 
for  this  purpose,  and  occasionally  proves  very  effi- 
cient ;  but  its  general  use  for  such  cases  is  of  doubt- 
ful propriety,  and  when  used,  it  should  be  with  dis- 
crimination and  caution. 

It  has  been  suggested  that  the  character  of  caries 
may  be  modified  by  the  local  application  of  thera- 
peutic agents — that  the  rapid  decay  may  be  changed 
to  the  slow,  and  this,  too,  without  regard  to  the  at- 
tendant circumstances,  such  as  the  condition  of  the 
secretions  of  the  mouth,  the  causes  producing  the  dis- 
ease, etc.  For  this  purpose  various  agents  have  been 
proposed.  It  is  held  that  by  an  application  of  the 
nitrate  of  silver,  the  white,  rapid  decay  being  changed 
to  that  of  a  dark  color,  is  arrested  in  its  progress. 
But  there  is  no  very  palpable  principle  on  which  this 
agent  can  be  supposed  to  operate  to  arrest  caries.  It 
is  generally  conceded  to  be  injurious  to  a  healthy 
tooth ;  how,  then,  it  becomes  beneficial  to  one  de- 
cayed, it  is  not  easy  to  perceive.  The  notion  may 
have  originated  in  the  fact  that  after  the  application 
of  nitrate  of  silver,  the  dentine  to  which  it  has  been 
applied  turns  dark,  or  black  ;  and  this  color  being 
naturally  associated  with  the  slow  form  of  decay,  it 
may  have  been  concluded  that  it  might  be  thus  asso- 
ciated by  artificial  means.  This  conclusion,  however, 
is  fallacious  ;  for  the  coloring  matter  being  the  oxide 


72  CARIES   OF    THE   TEETH. 

of  silver,  deposited  on  the  walls  of  the  cavity,  is 
wholly  foreign,  and  holds  no  necessary  relation  to  the 
kind  of  decay,  or  to  the  agent  producing  it.  The 
deposit  may  possibly  serve  as  a  temporary  shield  to 
the  dentine  beneath,  but  only  temporary ;  whereas, 
on  the  other  hand,  it  will  be  remembered  that  nitric 
acid  is  liberated  by  the  decomposition  of  the  nitrate, 
and  operates  destructively  upon  the  tooth-bone.  An 
ethereal  solution  of  the  terchloride  of  gold  has  also 
been  suggested  as  a  preventive  application.  Its  oper- 
ation would  be  much  the  same  as  that  of  the  nitrate  of 
silver,  and  equally  inefficient.  Preparations  to  neu- 
tralize and  counteract  the  effects  of  deleterious  agents 
upon  the  teeth  have  been  recommended  as  topical 
applications.  These  are  such  as  possess  alkaline 
properties.  But  anything  of  this  kind  would  require 
frequent  application  ;  indeed,  it  would  be  necessary 
to  keep  the  affected  part  constantly  under  its  influ- 
ence, as  long  as  the  surrounding  conditions  continued 
to  favor  decay. 

Though  nothing  of  this  kind  can  be  relied  upon 
permanently  to  arrest  caries,  yet,  in  many  instances, 
much  benefit  is  to  be  derived  from  local  treatment. 
Alkaline  topical  applications  will  in  many  cases 
alleviate  the  most  acute  sensitiveness  of  the  dentine, 
accomplishing  this,  no  doubt,  by  their  neutralizing 
influence  upon  the  irritating  agents.  Many  opera- 
tors employ  simply  the  bicarbonate  of  soda  for  this 


TREATMENT   OF    CARIES.  73 

purpose,  with  the  happiest  results.  As  another  class 
of  topical  applications  to  check  or  modify  caries, 
those  have  been  suggested  which  will  form  an  insol- 
uble compound  with  the  gelatinous  or  animal  portion 
of  the  tooth  ;  such  as  tannin,  creosote,  and  some  of 
the  essential  oils.  The  only  effect  of  these,  however, 
is  to  form  a  shield  or  protection  over  the  structure 
beneath :  there  is,  of  course,  no  change  effected  in 
the  conditions  or  agents  which  produce  decay. 


CHAPTER  III. 

GENERAL   REMARKS    ON    FILLING 

The  importance  and  value  of  the  operation  of  filling 
teeth  are  obvious,  from  various  considerations.  It  is 
one  that  is  in  frequent  requisition.  It  is  the  only 
treatment  for  deepseated  caries.  By  it  the  disease  is 
arrested  and  the  lost  part  restored,  so  far,  at  least,  as 
it  can  be  by  a  foreign  substance.  There  is  no  material 
similar  to  that  destroyed — no  substance  possessing  the 
characteristics  of  the  lost  portion  of  the  tooth,  with 
which  to  effect  the  restoration.  Under  favorable  cir- 
cumstances, the  operation  of  filling  is  efficient  in  ar- 
resting caries,  and  restoring,  to  a  greater  or  less  extent, 
the  lost  portion  of  the  tooth.  In  order,  however,  that 
it  be  permanent  in  its  character,  the  case  needs  to  be 
attended  with  favorable  conditions,  and  the  work  to 
be  thoroughly  done.  But  two  similar  operations,  both 
equally  well  performed,  may  result  very  differently  as 
to  ultimate  success  in  preserving  the  teeth  to  which 
they  may  have  been  applied ;  the  one  effectually  pre- 
venting further  decay,  and  the  other  seeming  to  inter- 
pose to  it  but  little  obstacle.  Indeed,  the  probabilities 
of  such  success  in  different  operations,  equally  well 


GENERAL    REMARKS   ON    FILLING.  75 

accomplished,  cannot  be  calculated  without  considering 
a  variety  of  circumstances,  such  as  differences  in  con- 
stitutions, in  states  of  health,  in  previous  and  subse- 
quent habits. 

Filling  teeth  is  predicated  upon  the  nature  of  decay, 
upon  the  fact  that  the  lost  portion  will  not  be  restored 
by  nature,  and  upon  the  fact  that  caries  is  an  effect  of 
external  causes,  and  not  of  any  cause  within  the  tooth 
itself.     If  the  causes  of  caries  were  alone  within  the 
tooth,  then  filling  would  not  be  its  rational  treatment. 
The  organic  structure  of  the  teeth  is  of  such  nature 
that  no  change  to  the  extent  of  decomposition  will 
take  place  in  it  independently  of  external  influences. 
Any  organ  or  structure  susceptible  of  becoming  dis- 
eased by  any  cause  resident  within  it,  usually  possesses 
the  power  of  recuperation,  and,  in  many  instances, 
that  of  restoration  also  ;  and  if  dentine  could  be  decom- 
posed without  external  agents,  the  introduction  of  any 
foreign  substance  whatever  into  the  cavity  would  cer- 
tainly not  arrest  the  decay,  but  most  probably  accele- 
rate it.     If  it  is  true  that  decay  of  the  teeth  ever 
originates  in  constitutional  causes  alone,  then  the  treat- 
ment should  be  constitutional,  and  not  local. 

rilling  teeth,  then,  is  based  upon  the  inability  even 
of  bealthy  dentine  to  prevent  the  occurrence  of  decay. 
As  preliminary  to  the  operation,  all  the  circumstances, 
both  dinct  and  collateral,  should  be  carefully  noted 
in  every  case,  and  the  course  of  treatment  should  con- 


76  GENERAL    REMARKS    ON    FILLING. 

form  to  the  indications  thus  observed.  The  constitu- 
tion, temperament,  and  health  of  the  patient ;  the 
peculiarities  of  the  teeth  ;  their  susceptibility  of  decay ; 
their  present  condition,  and  that  of  the  parts  about 
them ;  the  periosteum,  the  gums,  the  mucous  mem- 
brane, the  secretions  of  the  mouth,  the  saliva,  and  the 
mucus,  should  all  be  closely  considered  ;  for  only  on  a 
correct  diagnosis  can  a  proper  treatment  be  based. 
Every  operation  should  be  performed  as  completely 
as,  under  the  circumstances,  it  is  possible.  Indeed, 
every  step  in  the  operation  should  be  perfect,  before  a 
succeeding  one  is  attempted.  All  the  instruments  em- 
ployed should  be  unexceptionable  in  material,  form, 
and  condition ;  inferior  instruments  should  find  no 
place  in  the  case  of  the  dental  operator.  The  material 
for  filling  should  be  of  the  best  quality,  and  jDrepared 
in  the  best  possible  manner.  Not  that  material  for 
filling  should  be  prepared  in  only  one  way ;  for  some 
materials,  gold,  for  instance,  may  be  prepared  in  many 
different  forms,  each  perfect  in  its  kind,  and  efficient 
in  the  hands  of  the  expert  manipulator.  While  with 
instruments  and  materials  all  in  the  most  perfect  con- 
dition, and  with  a  thorough  cognizance  and  appre- 
ciation of  all  the  attendant  circumstances,  our  most 
skilful  operators  barely  attain  success,  need  we  be  as- 
tonished that  the  man  ignorant  of  all  these  circum- 
stances, and  possessed  of  only  a  few  crude,  ill-condi- 


GENERAL   REMARKS   OX   FILLING.  77 

tioned  instruments  and  materials,  the  nature  of  which 
he  does  not  understand,  fails  in  almost  every  attempt  ? 

Much  depends  on  therapeutic  treatment ;  not,  in- 
deed, to  restore  parts  already  lost,  or  to  restore  to 
health  parts  much  diseased,  hut  to  avert  a  tendency 
to  disease  in  parts  but  feebly  organized.  This  treat- 
ment may  be  either  constitutional  or  local,  or  both, 
but  constitutional  when  there  is  indicated  any  idio- 
syncrasy favorable  to  decay.  If,  however,  the  whole 
difficulty  is  local,  topical  treatment  only  is  required. 
AVhat  the  special  treatment  should  be  in  either  case 
will  be  more  fully  considered  hereafter.  Compara- 
tively little  can  be  accomplished  by  local  applica- 
tion to  the  substance  of  the  tooth,  but  the  parts  con- 
tiguous, as  the  gums  and  the  mucous  membrane, 
may  be  thus  treated  with  an  assurance  of  more  signal 
results. 

Though  in  the  teeth  nature  does  not  assist  to  restore 
a  lost  portion,  as  in  those  parts  more  highly  organ- 
ized, yet,  to  compensate  in  some  degree,  the  destruc- 
tive process  is  far  less  rapid  in  the  former  than  in 
the  latter.  The  general  surgeon  depends  much  upon 
nature  for  the  success  of  his  operations,  for,  though 
lie  performed  them  unskilfully,  yet  the  kind  energy 
of  nature  is  always  present  to  assist  him,  but  in  this 
specialty  the  practitioner  must  necessarily  depend 
more  upon  his  skill,  and  less  upon  the  curative  efforts 


78  GENERAL   REMAREB   OK    FILLING. 

of  nature,  though  much  more  reliance  is  placed  upon 
it  now  than  formerly. 


Materials  for  Filling. 

In  the  selection  of  materials  for  filling  teeth  there 
are  some  important  considerations  that  should  be 
kept  constantly  in  view ;  the  first  and  principal  of 
which  is  to  choose  that  kind  which  will  ]->rotect  the 
tooth  from  further  decay — protect  the  affected  part 
against  the  influence  of  those  agencies  on  which  the 
disease  depends.  A  material  or  class  of  materials 
should  be  selected  that  would  not,  under  any  cir- 
cumstances, induce  either  a  local  or  a  constitutional 
injury. 

There  are  several  properties  that  materials  for 
filling  teeth  should  possess,  one  of  the  most  impor- 
tant of  which  is, 

Indestructibility. — Any  substance,  whether  simple 
or  compound,  that  will  not  maintain  its  identity  and  in- 
tegrity when  subjected  to  any  conditions  of  the  mouth, 
is  unfit  to  be  used  as  a  material  for  filling.  If  com- 
pounds are  employed,  they  should  be  such  as  would 
not  be  affected  by  the  secretions  of  the  mouth,  or  by 
any  attendant  conditions.  A  mere  mechanical  mix- 
ture would  not  be  an  appropriate  material  for  per- 
manent filling,  and  all  compounds  of  the  metals,  so 
for  as  we  are  familiar  with  them,  are  unfit  for  this 


MATERIALS    FOR   FILLING.  79 

purpose  by  reason  of  the  facility  with  which  they  are 
changed  in  the  mouth.  The  next  most  important 
property  of  a  material  for  filling  is, 

Adaptability. — By  which  is  meant  a  capability  of 
being  wrought  into  suitable  shapes  for  the  purpose, 
— a  facility  of  being  applied  and  conformed  to  the 
parts  upon  which  it  is  to  be  placed.  There  are  sub- 
stances that  would  be  entirely  indestructible  in  the 
mouth,  and  that  would  be  very  desirable  in  other  re- 
spects as  materials  for  filling,  that  are  yet  altogether 
worthless  for  this  purpose  from  lack  of  adaptability. 
Quartz,  if  it  possessed  this  property,  would  be  valu- 
able as  a  material,  but  as  yet  there  has  been  discov- 
ered no  method  of  preparing  it  in  an  available  form. 
On  the  other  hand,  many  things  possess  the  property 
of  adaptability  that  are  lacking  in  some  other  impor- 
tant particulars.     The  next  important  property  is, 

Hardness. — A  material  may  possess  all  the  other 
suitable  qualities  and  yet  be  too  soft.  A  material 
should  be  hard  enough  not  to  be  broken  or  worn  away 
by  any  pressure  or  friction  liable  to  be  applied.  This 
property  is  especially  desirable  for  fillings  in  the  mas- 
ticatory surfaces  of  the  molars  and  bicuspids.  It 
would,  however,  be  admissible  fo  employ  a  softer  ma- 
terial for  filling  cavities  in  the  proximate  surfaces  of 
the  teeth,  provided  it  would  perfectly  exclude  all  for- 
eign substances. 

Non-conductor. — Again,  a   material  should    be   as 


80  GENERAL    REMARKS   <>\    FILLING. 

nearly  as  possible  a  non-conductor  of  heat,  particu- 
larly for  filling  sensitive  teeth,  or  those  liable  to  be- 
come so  under  the  influence  of  slight  causes.  Great 
variations  of  temperature  will  in  most  instances  aggra- 
vate sensitiveness,  and,  in  susceptible  cases,  produce  it; 
and  if  the  irritation  is  continued,  the  result  may  be 
fatal  to  the  tooth.  Gold,  which  possesses  the  largest 
number  of  desirable  qualities  as  a  material  for  filling, 
is  in  this  respect  very  defective,  being  one  of  the  best 
conductors  of  heat.  To  obviate  this  defect,  some  non- 
conducting material  may  be  employed  between  the 
gold  and  the  sensitive  portion  of  the  tooth.  The  pulp 
is  liable  to  be  affected  by  sudden  and  great  changes  of 
temperature,  transmitted  to  it  through  a  gold  plug. 

Cohesion. — In  the  next  place,  a  material  should  be 
susceptible  of  being  welded  or  united  into  a  solid  mass. 
The  permanency  of  an  operation  depends  very  much 
upon  this  quality.  A  filling  having  the  different  pieces 
which  compose  it  perfectly  united,  will  be  much  more 
durable  than  if  effected  with  a  material  in  which  this 
cohesive  property  is  lacking,  it  can  be  made  with 
greater  facility,  and  will  be  better  and  longer  retained; 
and  mainly  because  such  a  filling  cannot  be  destroyed 
piecemeal.  Xon-cohesive  material  is  retained  by  the 
general  form  of  the  cavity,  which  is  to  be  shaped  so 
as  to  bind  all  the  pieces  together,  and  thus  hold  them 
in  place ;  but  a  substance  that  will  weld  requires  only 
two  or  three  good  retaining  jDoints,  angles,  or  pits,  pro- 


MATERIALS   FOR   FILLING.  81 

perly  situated,  in  order  to  be  firmly  and  permanently 
fixed  in  a  cavity  of  any  form. 

Color. — Another  desirable  property  of  material  for 
filling:  is  such  a  color  as  shall  best  harmonize  with 
that  of  the  teeth,  particularly  if  they  are  in  front,  In 
this  respect  all  the  metals  are  objectionable,  though 
gold  is  probably  less  so  than  any  of  the  others,  the 
objection  to  this  being  not  so  much  in  its  color  as  in 
its  lustre  ;  which  objection,  however,  may  be  partially 
obviated  by  the  kind  of  finish  given  to  the  work.  In 
teeth  of  certain  shades — semi-transparent  bluish-white, 
for  instance — gold,  for  exposed  fillings,  is  very  objec- 
tionable, indeed,  in  some  cases,  almost  as  unsightly  as 
the  absence  of  the  tooth ;  and  in  such  instances,  the 
darker  metals  would  of  course  appear  much  worse. 
For  such  teeth,  some  substances,  having  more  nearly 
the  color  of  the  teeth,  would  be  the  more  desirable. 

Most  of  the  materials  employed  for  filling  are  me- 
tallic ;  only  a  few  non-metallic  substances  have  been 
used,  and  these  rather  by  the  way  of  experiment,  and 
for  temporary  purposes,  than  with  any  hope  t)f  perma- 
nent results.  Of  the  metals,  gold  possesses  more  of  the 
indispensable  properties  than  any  other;  but  the  fol- 
lowing have  been  used  for  filling  :  lead,  tin,  silver,  pla- 
tinum, gold,  and  amalgam.  In  the  preparation  of  the 
tatter,  gold, silver,  platinum,  tin,  bismuth,  antimony, 
cadmium,  zinc,  copper,  and  mercury  are  employed. 

Lead. — This   metal,   in    the  early  history  of  tin; 


82  GENERAL   REMARKS   ON   PILLING. 

profession,  was  used  to  some  extent  for  filling  teeth, 
though  it  possesses  but  few  of  the  requisites  for  thai 
purpose.  The  principal  quality  which  recommended 
it  is  its  adaptability  ;  but  it  is  quite  too  soft  for  per- 
manent fillings  in  the  masticating  surfaces  of  the 
molars.  It  is  easily  wrought  into  foil  and  welded 
into  mass  in  the  cavity,  but  it  is  rapidly  worn  down 
by  mastication,  and  its  integrity  readily  impaired  by 
the  influence  of  some  conditions  of  the  mouth ;  much 
more  readily,  indeed,  than  that  of  tin  or  silver.  Acetic 
and  some  other  acids  act  upon  it  with  considerable 
energy  in  the  mouth.  By  exposure  to  air  and  moist- 
ure, it  is  soon  coated  with  carbonate  or  protoxide  of 
lead ;  and  this  change  is  effected  much  more  readily 
in  the  mouth.  Lead  is  also  objectionable  in  color,  es- 
pecially for  fillings  in  the  anterior  teeth,  it  being 
darker  than  the  other  metals  employed  for  the  pur- 
pose. It  is  a  less  perfect  conductor  of  heat  than  some 
others  that  are  in  far  more  extensive  use. 

Tin.— This  metal  has  been,  and  is  even  yet,  much 
employed  as  a  material  for  filling.  It  is  easily 
wrought  into  foil,  and  in  that  condition  is  readily 
adapted  to  the  purpose,  by  reason  of  its  softness  and 
pliability.  Fillings  can  be  made  with  it  in  all  cases 
in  which  non-cohesive  gold  foil  can  be  used,  to  much 
of  which,  indeed,  it  can  by  skilful  manipulation  be 
made  superior  in  cohesive  property.  Its  equality, 
however,  is  greatly  dependent  on  the  manner  of  its 


MATERIALS    FOR    FILLING.  83 

manufacture.  It  is  harder  than  lead,  and  in  many 
cases  hard  enough  for  permanent  fillings  ;  it  is  fre- 
quently retained  in  crown  cavities  of  the  molars,  ef- 
fectually preserving  the  teeth  for  many  years.  In 
favorable  conditions  of  the  mouth,  it  is  not  materially 
changed,  not  oxidizing  easily,  and  not  readily  uniting 
with  any  substances  liable  to  be  brought  in  contact 
with  it.  But  in  an  unhealthy  mouth,  with  the  secre- 
tions in  an  abnormal  condition,  and  the  teeth  neg- 
lected, tin  fillings  are  very  rapidly  destroyed  by  the 
action  of  the  various  agents  that  may  come  in  contact 
with  them.  Such  a  change  may  take  place  in  the 
mouth  as  will  in  a  little  time  destroy  tin  fillings  that 
had  long  remained  in  good  preservation  ;  and  hence 
this  material  is  not  entirely  reliable  in  any  case,  since 
such  change  may  at  any  time  occur.  Some  ca^es 
seemingly  favorable  to  its  use  are  found,  on  examina- 
tion, to  be  otherwise;  and  in  almost  any  mouth  in 
which  there  is  a  large  proportion  of  mucus  secreted,  it 
cannot  be  depended  upon  for  permanency.  Its  color 
renders  it  unfit  for  the  anterior  teeth.  It  is  a  less  per- 
fect conductor  of  heat  than  gold,  on  which  account  it  is 
frequently  employed  where  the  latter  metal  cannot  be. 
There  are  cases  in  which  it  is  not  proper  to  use  tin  in 
connection  with  gold,  or  any  metal  having  a  marked 
difference  of  affinity  for  oxygen,  in  the  same  cavity. 

Thifi   applies  in    cases    in  which    cleanliness  is   not   ob- 

Berved,  or  where  there  Is  a  general  acid  slate  of  the 


84  GENERAL    REMARKS   ON    FILLING. 

mixed  saliva,  and  where  there  is  a  disposition  to  gal- 
vanic action.  In  the  more  favorable  cases,  however, 
it  may  be  employed  to  fill  the  interior  of  large  cavi- 
ties, placing  upon  it  a  covering  of  gold. 

Bui  -nine  of  the  plastic  materials,  as  now  presented, 
arc  better  for  this  purpose  than  tin.  Some  have  used 
tin  foil  mixed  with  gold  foil  for  filling,  the  tin  coming 
to  the  surface  equally  with  the  gold,  it  is  claimed 
that  rarely,  if  ever,  do  any  unfavorable  changes  oc- 
cur. Dr.  Abbott  of  Berlin  has  been  a  strong  advo- 
cate for  this  mode  of  practice.  The  use  of  this  ma- 
terial should  be  determined  by  the  constitutional  pre- 
disposition of  the  patient  and  the  character  of  the 
teeth,  which  should  be  dense  and  well  organized,  in 
order  to  render  it  practicable.  It  is  frequently  very 
valuable  for  filling  the  temj^orary  teeth,  and  for  tem- 
porary use  in  the  permanent  teeth. 

Silver. — This  metal,  in  the  form  of  foil,  has  never 
been  used  for  filling  teeth  except  experimentally.  It 
is  not  for  this  purpose  superior  to  tin  in  any  particu- 
lar, except  in  being  somewhat  harder;  and  in  some 
particulars  it  is  inferior,  being  quite  as  destructible  in 
the  mouth ;  more  easily  affected  by  certain  agents, 
such  as  nitric  acid,  nascent  chlorine,  etc. ;  less  pliable 
and  less  adaptable ;  more  difficult  to  work  into  foil ; 
not  so  readily  formed  into  fillings ;  and  possessed  of 
much  less  cohesiveness,  being  almost  unweldable  by 
the  ordinary  method  of  manipulation.     Silver  is  a 


MATERIALS    FOR    FILLING.  85 

better  conductor  than  tin,  and  would  therefore  in  many 
eases  be  more  objectionable.  The  saliva  is  often  in 
such  a  condition  as  to  act  upon  it  with  rapidity.  Its 
color,  too,  is  objectionable.  Having  these  disadvan- 
tages, its  use  has  very  properly  never  been  adopted. 

Platinum. — This  metal  has  been  but  little  used  for 
the  purpose  of  filling,  though  it  possesses  some  of  the 
requisite  qualities  in  a  very  high  degree ;  as,  for  in- 
stance, indestructibility,  in  which  property  it  is  supe- 
rior to  gold.  In  other  respects,  however,  it  is  very 
deficient;  it  has  not  as  yet  been  wrought  into  any 
form  in  which  it  can  be  welded  with  facility;  it  is 
difficult  to  work  into  foil,  and  when  it  is  put  into  this 
form,  it  possesses  a  stiffness  and  harshness  that  render 
its  adaptation  and  condensation  almost  impracticable. 
It  is  more  on  this  account,  perhaps,  than  on  any  other, 
that  it  has  been  so  little  employed  for  the  purpose  of 
filling.  It  has  also  less  cohesiveness  than  gold,  and 
much  sooner  parts  with  this  property.  Slight  crump- 
ling or  bending  serves  to  stiffen  it,  so  as  to  destroy  its 
applicability.  Good  fillings  may  be  made  of  well- 
prepared  platinum  sponge,  recently  annealed.  It  re- 
quires skilful  manipulation,  however,  for  the  least 
moisture  destroys  its  cohesive  property  entirely.  It 
is  a  good  conductor  of  heat,  and  on  this  account  objec- 
tionable. In  the  respect  of  color,  too,  it  is  undesirable. 
Platinum  should  never  be  placed  in  close  proximity 
to  tin  fillings,  or  to  gold  plate  or  clasps  of  low  carat. 


86  GENERAL    REMARKS   ON    PILLING. 

It  is,  however,  being  employed  to  some  extent  in  con- 
nection with  gold,  which  in  some  respects  seems  to 
serve  a  valuable  purpose.  It  is  used  in  the  form  of 
foil,  of  an)'  desired  thickness,  heavily  coated  with  pure 
gold.  The  claims  for  this  combination  are,  that  a  far 
harder  and  more  resistant  filling  can  be  made  than 
with  gold  alone,  and  a  modification  of  the  color  of  the 
gold  that  is  far  preferable  for  teeth  of  certain  shades 
of  color. 

Gold. — Of  all  the  metals  that  have  as  yet  been  used 
for  filling  teeth,  gold  possesses  more  of  the  requisite 
properties  than  any  other,  and  sufficiently  so  for  all 
practical  purposes.  Twenty-carat  gold  is  very  seldom 
affected  by  any  agencies  with  which  it  is  brought  in 
contact  in  the  mouth  ;  pure  gold  never.  In  the  filling 
of  teeth,  there  are  two  objects  to  be  aimed  at :  one,  a 
sufficient  hardness  to  withstand  the  wear  of  mastica- 
tion ;  the  other,  a  thorough  protection  to  the  cavity 
agaiust  all  decay-producing  agents.  For  the  attain- 
ment of  the  first  of  these,  gold  is  not  all  that  could  be 
desired ;  yet  it  is,  perhaps,  as  efficient  in  this  respect 
as  any  other  metal  that  can  be  employed.  But  the 
second  object,  gold,  when  well  manipulated,  accom- 
plishes very  effectually :  that  is,  so  long  as  the  filling 
maintains  its  integrity  ;  after  it  is  partially  worn  out,  it 
thus  far  fails,  of  course.  In  adaptability,  too,  gold  is 
superior  to  any  other  metal.  It  can  be  wrought  into 
a  variety  of  forms,  with  any  of  which  very  good  fill- 


MATERIALS    FOR    FILLING.  87 

ings  can  be  made.  It  can  be  perfectly  conformed  to 
any  shape  of  surface,  however  irregular.  A  tooth  that 
can  be  filled  at  all,  can  be  filled  with  gold.  This  as- 
sertion was  made  a  number  of  years  ago ;  and  if  it  was 
true  then,  it  is  much  more  true  now ;  for  then  the 
cohesive  property  of  gold  was  not  employed  at  all,  or 
even  recognized  as  available ;  but  now,  this  property 
has  been  rendered  efficient  and  practicable.  Then,  our 
best  operators  did  not  aim  to  unite  the  different  por- 
tions of  gold  of  which  the  fillings  were  composed.  The 
idea  that  such  consolidation  could  be  effected  seemed 
never  to  have  entered  the  mind  of  any  one.  Indeed, 
with  the  instruments,  and  the  method  of  manipulation 
then  employed,  this  cohesive  property  could  not  have 
been  made  available ;  but  as  it  came  to  be  recognized, 
the  instruments  and  the  manipulations  were  adapted 
to  the  purpose.  Formerly,  an  ordinary  gold  plug 
when  removed  from  a  cavity  could  be  readily  separated 
into  as  many  pieces  as  originally  composed  it;  but 
now,  when  cohesive  gold  is  skilfully  used,  the  mass 
composing  a  filling  cannot  be  divided  into  its  original 
parts,  but  may  be  wrought  into  plate,  wire,  or  foil. 
Non-cohesive  gold — the  modification  in  which,  till 
about  the  year  18.30,  it  was  always  employed — would 
not  weld,  even  under  great  pressure;  but  in  the  mode 
in  which  it  is  now  prepared,  it  will  weld  readily  and 
thoroughly.  There  are  certain  requisites  essential  to 
thifl  welding  property  of  gold.     If  it  is  in  the  form  of 


88  GENERAL  REMARKS   ON    FILLING. 

foil,  it  should  not  present  a  smooth,  planished  surface; 
it  musl  be  annealed  after  hammering,  in  order  that 
its  ultimate  particles  may  be  in  the  best  condition  for 
cohering;  it  must  be  entirely  free  from  all  deposit-  of 
foreign  substances;  and  it  must  be  kept  from  exposure 
to  the  atmosphere. 

Gold  is  a  good  conductor  of  heat,  and  this  is  the 
chief  objection  to  it  as  a  material  for  filling.  As  to 
sensitive  teeth  this  is  a  very  serious  objection,  in  some 
cases  necessitating  the  employment  of  non-conducting 
material  beneath  it,  and  in  others  precluding  its  use 
altogether.  The  color  of  gold,  however,  is  seldom  an 
objection  to  its  use,"though  it  sometimes  renders  it  un- 
suitable for  fillings  in  the  front  teeth.  But  this  objec- 
tion has  been  already  adverted  to. 

Various  Preparations  of  Gold. — And  first,  of  the 
manufacture  of  gold  foil.  For  this  purpose  pure  gold 
is  used,  for  procuring  which  various  methods  are  em- 
ployed. But  the  most  common  of  these  are  insuffi- 
cient for  the  production  of  gold  absolutely  pure.  It 
is,  however,  deemed  irrelevant  here  to  detail  the  pro- 
cess by  which  this  end  is  attained ;  it  is  enough  to 
premise  that,  for  the  manufacture  of  the  best  quality 
of  foil  pure  gold  is  indispensable.  The  gold  is  cast 
into  an  ingot  about  an  inch  wide,  is  then  placed  be- 
tween a  pair  of  rollers  and  milled  down  as  thin  as 
practicable,  the  piece,  while  in  this  process,  being  fre- 
quently annealed.     It  is  then  cut  into  squares,  which 


MATERIALS    FOR   FILLING.  89 

are  inserted  with  wooden  pliers  between  vellum  leaves, 
a  hundred  and  sixty  or  seventy  in  a  pack.  Over  this 
paek  two  pockets  are  drawn,  inclosing  it  completely. 
The  pack  is  then  hammered  on  a  granite  block  with 
a  hammer  weighing  twelve  or  sixteen  pounds  till  the 
leaves  are  spread  out  to  the  full  extent  of  the  pack. 
They  are  then  removed  from  the  pack,  cut  into  four 
sections,  annealed,  replaced  in  the  pack,  and  again 
subjected  to  the  hammer;  this  process  is  repeated  till 
the  desired  thickness  of  foil  is  obtained.  Much  ex- 
perience and  skill  are  requisite  to  the  proper  accom- 
plishment of  this  part  of  the  work.  By  a  single  un- 
skilful stroke  of  the  hammer  a  whole  pack  may  be 
spoiled. 

Gold  foil  is  numbered  according  to  the  grains  con- 
tained in  each  leaf,  ranging  from  2  to  240.  The  most 
common  numbers  are  4,  6,  10,  20,  30,  60,  120,  and 
240 — the  latter  two  are  seldom  used.  Of  the  smaller 
numbers,  4  and  6  are  in  most  frequent  use.  It  has 
heretofore  been  a  desideratum  to  obtain  gold  foil  per- 
fectly uniform  in  quality.  This  seems  now  to  be  al- 
mosl  if  uot  altogether  attained  by  the  more  careful 
and  skilful  manufacturers. 

Crystal  Gold. — This  form  of  gold  was  introduced 
to  the  profession  aboul  twenty-eight  years  ago.  Some 
experiments  in  this  direction,  indeed,  had  been  made 
;i-  early  as  1825,  byC.  Ash,  of  London,  and  again  in 
1850,  by  j  )r.  s.  A.  Main,  of  New  York.  Their  prepara- 


90  GENERAL    REMARKS   ON    PILLING. 

tions,  however,  were  simply  precipitates,  and  nothing 
more.  But  in  1853,  Dr.  A.  J.  Watts,  of  Utica,  New 
York,  obtained  letters  patent  for  this  preparation  of 
gold  for  filling  teeth.  This  preparation  was  at  first 
denominated  sponge  gold,  but  after  some  modification 
received  its  present  name.  There  are  numerous  for- 
mulas by  which  preparations  of  crystal  gold  may  be 
made,  but,  so  far  as  we  are  acquainted  with  them,  they 
are  all  embraced  in  two  general  methods:  the  one  to 
obtain  simply  a  precipitate  of  the  metal  adaptable  to 
the  filling  of  teeth ;  and  the  other,  to  combine  this 
precipitate  with  mercury,  and  obtain  a  definite  crystal- 
lization. For  the  preparation  of  the  sponge  or  crystal 
gold  the  absolutely  pure  metal  is  required.  This  is 
dissolved  in  nitro-muriatic  acid,  the  gold  being  added 
till  the  solution  is  saturated.  Various  materials  may 
be  used  to  precipitate  it,  the  most  common  of  which 
are  sulphate  of  iron,  and  oxalic  acid,  the  latter  on  some 
accounts  being  preferable.  The  character  of  the  pre- 
cipitate will  be  determined,  in  a  great  degree,  by  the 
manner  in  which  the  precipitant  is  added ;  if  slowly, 
the  precipitate  will  take  a  more  definite  form,  inclining 
to  the  crystalline  or  fibrous. 

A  preparation  may  be  made  by  introducing  the 
precijritant  gradually,  and  then  carefully  washing  the 
precipitate  and  heating  almost  to  redness.  For  per- 
fect crystallization  of  the  gold,  combine  the  precipitate 
with  from  six  to  twelve  times  its  weight  of  pure  mer- 


MATERIALS    FOR    FILLING.  91 

cury;  let  it  stand  a  short  time,  subject  to  a  gentle 
heat,  and  then  remove  the  mercury  with  dilute  nitric 
acid.  Afterward  wash  the  nitrate  of  mercury  from 
the  gold ;  place  the  latter  upon  a  slide,  and  bring  it 
to  a  full  red  heat  in  a  muffle,  and  the  gold  is  then  in 
a  condition  to  be  used  for  filling.  This  is  about  the 
formula  upon  wdiich  a  patent  was  granted  to  A.  J. 
Watts.  The  preparation  possesses  some  advantages 
over  gold  foil.  It  is  as  readily  introduced  ;  it  is  more 
capable  of  thorough  consolidation  ;  it  has,  besides  the 
cohesiveness  of  foil,  the  additional  property  of  inter- 
lacing its  crystals  one  with  another,  by  which  property, 
even  without  cohesion,  the  pieces  of  a  filling  can  be 
firmly  united,  and  it  takes  a  better  hold  upon  the 
walls  of  the  cavity,  to  which  it  presents  the  angles  and 
ends  of  the  crystals,  so  as  to  be  more  thoroughly 
adapted  and  fastened. 

Amalgam. — By  this  term  are  designated  all  those 
preparations  formed  by  a  combination  of  mercury  with 
various  other  metals;  most  frequently  with  silver  and 
tin,  but  occasionally  with  gold,  platinum,  bismuth, 
cadmium,  zinc,  and  lead.  The  several  formulas  for 
amalgam  need  not  here  be  specified.  The  kind  most 
in  use  is  prepared  by  melting  together  and  carefully 
mixing  pure  tin  and  silver,  filing  this  mixture,  when 
cooled,  into  dust,  combining  the  latter  with  mercury 
in  sufficient  proportion  to  give  the  requisite  plasticity, 
and  then  thoroughly  washing  the  whole  in  alcohol  or 


92  C4ENERAL   REMARKS   ON    PILLING. 

boiling  water,  to  remove  the  oxides  formed  during  the 
combination  of  the  metals.  If  there  is  a  redundance  of 
mercury,  it  may  be  removed  by  pressing  the  paste  in  a 
piece  of  chamois  skin.  This  preparation  may  in  some 
cases  be  used  for  filling  with  considerable  success  ;  but 
inno  case  can  it  be  relied  upon  as  a  durable  material, 
its  destructibility  being  no  less  than  that  of  tin  or  sil- 
ver in  any  circumstances,  and  being  greater  where  all 
the  excess  of  mercury  is  not  removed  from  the  surface 
of  the  filling,  and  the  surface  not  burnished  down  solid 
and  smooth.  Mercury  oxidates  with  considerable 
rapidity  when  exposed  to  air  and  moisture,  and  with 
increased  energy  under  the  influence  of  heat,  espe- 
cially when  some  acid  is  present.  This  facility  of 
oxidation  is  still  increased  when  other  metals  are 
combined  with  mercur}^.  Oxidation  of  such  fillings 
will  in  some  cases  be  confined  to  the  surface,  wherever 
there  is  contact  of  moisture ;  in  others,  it  will  pervade 
the  whole  mass,  rendering  it  black  and  spongy  through- 
out. 

Amalgam  fillings,  in  a  short  time  after  their  inser- 
tion, undergo  a  hardening  process,  occasioned  by  crys- 
tallization of  the  mass,  as  well  as  by  evaporation  of  the 
mercury.  The  consequence  is,  either  that  the  mass 
becomes  porous,  or  that  it  contracts;  the  former,  doubt- 
less, in  cases  where  the  oxidation  extends  through, 
and  the  latter  where  it  is  confined  to  the  surface. 
"When  a  filling  is  in  either  of  these  conditions,  the  pre- 


MATERIALS    FOR   FILLING.  93 

servation  of  a  tooth  is  very  uncertain.  On  removing 
an  ordinary  amalgam  filling  that  has  been  worn  for 
some  time,  its  entire  surface  will  generally  he  found 
oxidized  ;  and  a  tooth  filled  with  this  material  gener- 
ally becomes  blackened,  and  its  appearance  ruined. 

To  such  objections  against  this  material,  another 
is  to  be  added  in  cases  in  which  there  are  fillings  or 
plate,  of  platinum  or  gold:  galvanic  action  will  often 
be  established,  in  a  degree  proportionate  to  the  prox- 
imity and  extent  of  surface  of  the  metals  and  the  con- 
dition of  the  secretions.  This  may  occasion  much 
mischief.  Some  constitutions  are  very  susceptible  to 
the  influence  of  mercury ;  and  a  gradual  decomposi- 
tion of  several  amalgam  fillings  in  the  mouth  may 
seriously  impair  the  general  health.  Therefore,  before 
tli is  material  is  employed,  the  health,  temperament  and 
habits  of  the  patient  should  be  carefully  noted;  for 
these  and  other  circumstances  may  often  indicate  its 
inadmissibility. 

So  great  and  so  numerous  are  the  objections  to  this 
material,  that  it  is  wholly  discarded  by  some  in  the 
profession,  and  but  sparingly  used  by  a  great  many 
others.  Its  adaptability  is  the  main  property  on  which 
are  based  the  arguments  in  its  favor.  It  is  easily  ap- 
plied, and  becomes  very  hard  upon  crystallizing.  It 
is  affirmed,  also,  that  teeth  which  cannot  be  saved 
with  anything  else  may  be  filled  with  this,  and  made 
valuable.      This,  however,  is  not  true  since  the  em- 


94  GENERAL    REMARKS   <>N    PILLING. 

ploymenl   of  the   cohesive  property   of  gold,  which 
quality   renders  this  metal  equal   in   adaptability  to 

amalgam. 

Oxy-chloride  of  Zinc. — This  preparation  consists  of 
oxide  of  zinc,  and  chloride  of  zinc  in  combination. 
As  a  plastic  filling  it  has  been  extensively  used,  and 
when  properly  prepared,  and  rightly  employed,  with 
favorable  conditions  in  the  mouth,  serves  a  valuable 
purpose.  Such  fillings  are  often  found  after  many 
years  use  intact,  so  far  as  wasting  is  concerned,  and 
affording  absolute  protection  to  the  cavities  in  which 
they  are  placed. 

But  these  fillings  will  not  withstand  the  attrition 
of  direct  contact  in  mastication. 

The  oral  secretions  in  some  conditions  are  rapidly 
destructive  to  this  material.  It  is  one  of  the  best 
materials  for  temporary  fillings.  A  little  experience 
renders  its  use  easy.  It  effectually  excludes  all  foreign 
substances,  is  a  good  non-conductor,  and  is  only  dis- 
placed by  wear  and  the  solvent  power  of  the  saliva  in 
some  vitiated  conditions.'  Guilloi's  Cement,  and  Ce- 
ment Plomb  are  preparations  in  all  practical  aspects 
similar  to  oxy-chloride  of  zinc.  Some  variation  in  the 
method  of  manipulating  them  is  required.  There  is 
found  some  difference  of  susceptibility  in  these  different 
preparations  to  the  vitiated  secretions  of  the  mouth.  It 
is  a  good  protection  to  sensitive  dentine,  and  in  many 
cases  for  exposed  pulp,  under  gold  filling.       It  more 


MATERIALS    FOR    FILLING.  95 

nearly  resembles  the  natural  teeth  in  color  than  any 
other  material  that  has  been  used  for  filling". 

Oxy-phosphate  of  Zinc  is  being  largely  employed 
instead  of  the  chloride. 

It  is  more  permanent  than  the  chloride  in  the  secre- 
tions of  the  mouth,  and  withstands  the  wear  of  masti- 
cation, equally  as  well  if  not  better,  than  the  latter. 

To  sensitive  dentine,  and  even  to  exposed  pulps,  it 
is  far  more  acceptable  than  the  chloride,  because  of  its 
non-irritant  quality  ;  its  direct  application  to  highly 
sensitive  tissue  does  not  produce  pain  nor  irritation: 
The  chlorine  in  almost  every  instance  when  applied  to 
such  tissue  produces  intense  pain. 

The  Phosphate  possesses  the  property  of  hardening 
in  the  saliva. 

Non-metallic  Materials. — Of  the  non-metallic  ma- 
terials employed  for  filling  teeth  there  are  not  many 
worthy  of  any  particular  consideration.  Indeed, 
gutta-percha  and  its  preparations  constitute  the  chief 
of  these  substances  now  used  for  this  purpose,  though 
some  others  have  been  employed.  Gutta-percha  is 
useful  for  temporary  fillings,  and,  under  ordinary  cir- 
cumstances, is  sufficiently  durable.  It  is  valuable 
for  filling  those  teeth  which  it  may  be  desirable  to 
retain  only  a  short  time,  or  those  in  which  it  may  be 
necessary  temporarily  to  protect  a  sensitive  part 
againsi  the  influence  of  irritating  agents,  in  order  to 
restore  it  to  health.     Gutta-percha  is  not  readily  do- 


96  GENERAL    REMARKS   ON    FILLING. 

composed  by  the  fluids  of  the  mouth,  when  they 
are  in  a  healthy  condition.  In  some  instances  we 
have  known  it  worn  in  the  mouth  for  years  with  but 
little  change.  But  in  the  cavities  on  the  grinding 
surfaces  of  the  molars  and  bicuspids,  it  will  not  with- 
stand the  wear  of  mastication  a  great  while,  though 
long  enough  in  most  cases  to  subserve  the  purposes  of 
temporary  fillings.  It  possesses  great  adaptability. 
By  simply  being  warmed  over  a  spirit-lamp  or  in 
boiling  water,  it  becomes  plastic,  and  is  with  great 
facility  introduced  and  conformed  to  the  cavity.  It 
may  be  applied  also  in  solution,  being  dissolved  in 
chloroform  till  it  approaches  a  pasty  consistence,  then 
used  in  a  pledget  of  cotton,  and  introduced  into  the 
cavity,  where  the  chloroform  evaporating,  leaves  the 
gutta-percha  as  a  filling.  The  only  objection  to  this 
method  is  the  contraction  consequent  on  the  evapora- 
tion of  the  chloroform.  Another  property  that  ren- 
ders this  substance  highly  valuable,  is  its  non-conduc- 
tion of  heat,  it  being  in  this  respect  as  nearly  perfect 
as  any  other  material  employed. 

A  preparation  of  gutta-percha  with  mineral  sub- 
stances, known  as  Hill's  stopping,  has  for  many  years 
been  extensively  used  for  temporary  fillings ;  indeed, 
it  has  superseded  simple  gutta-percha  almost  entirely. 
The  aim  of  this  preparation  was  to  obviate  two  or 
three  objections  to  pure  gutta-percha;  as,  its  contrac- 
tibility  in  the  cavity,  its  softness  and  its  color.     The 


MATERIALS    FOR    FILLING.  97 

composition  of  HilFs  stopping  is  as  follows:  With 
pure  gutta-percha  in  a  plastic  state  are  mixed  quick- 
lime two  parts,  and  quartz  and  feldspar  one  part  each, 
which  latter  are  reduced  to  an  impalpable  powder, 
and  kneaded  into  the  mass  as  long  as  it  will  receive 
them  without  becoming  brittle.  Such  is  the  formula 
given  by  the  inventor  of  this  preparation  ;  though  it 
is  presumed  that  one  of  these  materials  alone,  namely, 
pulverized  quartz,  would  be  found  entirely  sufficient, 
since  it  is  capable,  by  itself,  of  quite  as  much  as  is  at- 
tained by  all  together.  The  addition  of  gold  or  pla- 
tinum fillings  has  been  recommended  ;  but  no  advan- 
tage is  thus  gained.  It  was  at  first  claimed  for  this 
material  that  it  would  serve  for  permanent  filling ; 
but  it  was  soon  demonstrated  to  be  insufficient.  It 
was  supposed,  also,  that  it  might  be  employed  for  j^ar- 
tial  fillings  in  large  cavities,  which  could  be  completed 
with  gold  ;  but  for  this,  too,  it  was  found  impracticable, 
since  it  did  not  make  a  sufficiently  firm  foundation. 

This  preparation  is  applied  in  the  same  manner  as 
simple  gutta-percha,  being  warmed  on  a  porcelain  or 
metal  slab  over  a  spirit-lamp  till  sufficiently  soft,  and 
then  packed  into  the  cavity.  It  cannot  be  employed 
in  the  form  of  solution,  nor  should  it  be  softened  in 
boiling  water.  It  may  be  conveniently  prepared  by 
dissolving  the  gutta-percha  in  chloroform  to  almost  a 
pasty  consistence,  then  adding  the  mineral  substances, 
and  putting  it  into  a  vessel  suitable  for  the  evapora- 


98  GENERAL    REMARKS   OX    PILLING. 

lion  of  the  chloroform.  It  should  be  made  so  thick 
that  the  silex  would  not  fall  to  the  bottom.  When 
Hill's  stopping  or  gutta-percha  is  used,  as  soon  as  the 
cavity  is  filled  an  instrument  with  the  end  nearly  as 
large  as  the  orifice  of  the  cavity  should  be  j)laced  upon 
the  filling,  and  retained  there  with  considerable  pres- 
sure till  the  mass  is  cool.  After  cutting  and  dressing 
the  surface  of  the  filling  as  thoroughly  as  can  be  with 
instruments,  then  by  passing  over  the  surface  a  short 
camel's-hair  brush,  with  chloroform,  a  very  smooth 
surface  and  perfect  finish  will  be  made.  In  some  re- 
spects, there  is  perhaps  nothing  better  for  temporary 
fillings  than  this  preparation  of  gutta-percha. 


CHAPTER  IV. 

INSTRUMENTS    FOR    FILLING. 

In  describing  the  instruments  for  filling  teeth,  it 
'will  be  convenient  to  take  them  somewhat  in  the  order 
in  which  they  are  employed  in  ordinary  practice  ;  first 
referring  to  those  which  are  used  for  cutting  away 
portions  of  the  teeth,  for  the  purpose  of  separating 
them,  and  for  dressing  off  the  borders  of  cavities  ;  then 
to  those  for  removing  decay  and  forming  the  cavities ; 
and  finally  to  those  for  introducing,  consolidating,  and 
finishing  fillings.  The  first,  then,  that  claim  our  at- 
tention, are  the 

Heavy  Cutting-insteilm  ents. 

These  are  of  chisel-shape.  They  should  be  of  good 
steel,  well  wrought,  and  thoroughly  tempered.  Every 
step  in  the  process  of  their  manufacture  should  be 
most  perfectly  executed,  so  as  to  insure  an  edge  that 
will  cut  not  only  dentine,  but  also  enamel,  which  is 
the  hardest  animal  substance.  Various  sizes  of  the 
3traighl  chisel-form  are  required. 

They  should  be  no  thicker  than  is  required  for 
strength,  they  should  be  stiff,  that  there  may  be  no 
springing  or  tremulous  motion  under  the  pressure  they 


100 


INSTRUMENTS    Foil    PILLING. 


are  required  to  sustain.     For  separating  front  teeth, 
they  must  be  thin  enough  to  pass  readily  into  the  in- 


Fi< 


tended  space,  and  about  one-fourth  of  an  inch  wide  at 
the  edge.  But  for  separating  bicuspids  and  molars, 
the  instruments  should  be  thicker  and  broader  ;  as, 


Fig.  4. 


thick,  indeed,  as  the  required  space  will  admit.     In 
some  cases  they  should  have  the  edge  oblique,  as  in 


Fig.  5. 


Fig.  5. 


It  is  seldom  that  these  instruments  need  any  curve. 
The  straight  form  is  the  best,  unless,  as  rarely  hap- 
pens, the  point  to  be  operated  upon  cannot  be  reached 


Fig.  6. 


efficiently  with  it ;  as,  for  instance,  in  a  small  mouth, 
a  slight  anterior  curve  will  be  required  in  the  shaft  of 
the  instrument,  to  facilitate  its  approach  to  the  front 
proximate  surface  of  a  second  or  a  third  molar.     Fig.  6, 


DRILLS. 


101 


a  heavy  instrument,  with  a  sharp  point  and  a  lateral 
curve,  is  often  efficient  in  opening  up  cavities  and  cut- 
ting down  strong  projections  of  enamel.  Fig.  7  we 
consider   as  a  very  valuable  form.     Every  operator 


Fig 


should  have  at  hand  a  sufficient  variety  to  meet  every 
demand — about  three  sizes  of  each  form. 

These  instruments  are  now  made  with  steel  handles, 
much  smaller  than  those  represented  above,  and  are 
used  with  a  mallet. 

Fig.  8. 


(  \/ 


The  above  (Fig.  8)  will  give  an  idea  of  the  variety 
of  Bizes  that  are  desirable. 


Drills. 

Bur  Drills. — Of  this  indispensable  class  of  instru- 
ments there  are  various  forms.    They  should  be  manu- 


102  [NSTRTTMENT8    F<>U    PILLING. 

factured  of  tin'  besl  steel,  and  wrought  with  the  greatest 
care.  After  having  been  forged  as  near  the  proper 
size  as  possible,  the  bulb  is  shaped  by  dressing  with  a 
fine  file,  or,  which  is  better,  by  turning  in  a  lathe, 

Fig.  9.' 


those  made  by  the  latter  method  being  superior,  and 
cutting  much  more  smoothly ;  they  do  not  catch  and 
jar  as  do  those  of  less  regular  form.  After  the  bulb 
is  formed,  it  is  cut  with  a  sharp-edged  file. 

Fig.  10. 


Of  these  drills,  Fig.  9  represents  a  bur  of  a  spherical 
form.  Fig.  10  is  cone-shaped,  which  may  have  various 
degrees  of  bevel,  terminating  in  a  sharp  point.  Fig.  11 
is  of  a  cylindrical  form,  cut  upon  the  sides  and  end. 

Fig.  11. 


Fig.  12  is  in  the  form  of  a  wheel,  cut  upon  the  edge 
only,  or  upon  both  the  edge  and  the  end.  The  cutting 
upon  all  of  these  should  be  very  regular  and  uniform. 
This   should    be    made  by  machinery,   though   it   is 


DRILLS.  103 

usually  done  by  hand.  Of  these  instruments,  there 
should  be  a  variety  in  size,  the  smallest  considerably 
less  than  the  smallest  cavity  the  dentist  ever  attempts 
to  fill — that  is  about  one  thirty-second  of  an  inch  in 
diameter,  and  the  largest  about  one-fifth  of  an  inch. 
Inclusive  of  these  extremes,  there  should  be  five  or  six 
sizes  of  each  particular  form.  These  instruments  are 
used  for  opening  cavities.  With  them  a  more  regular 
and  perfect  orifice  is  made  in  small  and  medium-sized 
cavities  than  by  any  other  method.     They  are  also 

Fig.  12. 


used  to  some  extent  for  forming  the  cavities,  and  even 
sometimes,  in  large  cavities,  for  making  retain  ing- 
points  for  a  filling. 

The  dental  engine  is  now  so  generally  used  that  the 
hand-drill,  as  shown  in  these  figures,  is  seldom  if  ever 
used,  but  the  points  here  shown  are  used  with  the 
engine. 

Borne  years  ago,  Dr.  Scranton  devised  a  rather  pe- 
culiar kind  of  drill,  and  efficient  withal.  Its  form  is 
spherical,  and  in  its  manufacture  the  bulb  is  made  as 
for  the  ordinary  bur  drill;  but,  instead  of  having  cut 
upon  it  numerous  serrations,  thus  forming  a  series  of 
sharp  edges,  a  concave  cul  is  made  upon  two  opposite 
with  a  small  round  file  The  instrument  then 
presents  two  concave  and  two  convex  sides  with  four 


104  [N8TRUMENT8    FOB    FILLING. 

sharp  longitudinal  edges;  these  may  be  so  inclined 
as  to  cut  only  when  rotated  in  one  direction,  or  to 
operate  alike  well  when  rotated  either  to  the  right  or 
the  left. 

This  instrument  has  two  or  three  advantages  over 
the  ordinary  bur ;  it  can  be  kept  sharp  with  the  oil- 
stone till  it  is  almost  entirely  used  up,  and  will  conse- 

Fig.  13. 

Z 


quently  last  much  longer,  and  will  cut  much  more 
rapidly  than  the  serrated  bur.  It  is  a  very  valuable 
instrument  for  operating  upon  firm,  strong  teeth.  It 
is  represented  in  Fig.  13. 

Common  Drills. — Of  other  drills,  Fig.  14  represents 
one  with  a  square   point,  bevelled  from  both   sides, 

Fig.  14. 


measuring  from  a  half  to  a  whole  line  in  width,  and 
attached  to  a  small  round  shaft.  The  edges  of  the 
drills  should  be  very  hard,  so  that  they  may  cut  with 
the  greatest  celerity.  Of  this  kind  there  should  be 
about  ten  sizes,  ranging  in  width  from  No.  12  to  No. 
25  of  Stubb's  gauge.  These  are  used  mainly  for  form- 
ing retaining-points  in  cavities. 

Fig.  15  is  the  spear-shaped  drill,  the  edges  of  which 


DRILLS 


105 


are  formed  by  dressing  from  both  sides,  or,  it  may  be, 
from  only  one,  in  which  case  it  will  cut  only  when 
rotating  one  way.     This  shape  is  employed  princi- 


Fig.  15. 


pally  for  drilling  roots  for  filling,  or  receiving  pivot- 
teeth. 

The  burs  and  drills  may  be  made  of  pieces  of  wire 
one  inch  and  a  half  long,  and  fitted  to  a  socket-han- 


Fig.  10. 


die  that  will  accommodate  a  large  number  ;  or,  of  a 
continuous  piece  of  large  wire.  The  latter  is  the  pref- 
erable  method,  Bince  much  time  is  consumed  in  chang- 
ing them  in  Bockets.     The  handles  should  be  made 


100  INSTRUMENTS    For:    PILLING. 

with  six  or  eight  sides,  and  cut  on  each  alternate  side. 
In  the  use  of  these  instruments  the  drill-ring  is  almost 
indispensable.  This  is  a  ring  used  on  the  middle  or 
index  finger,  with  a  socket  attached,  in  which  rests 
the  end  of  the  handle  of  the  instrument.  (Fig.  16.) 
The  drill  is  rotated  commonly  with  the  thumb  and 
fingers. 

Drill-stocks  of  various  forms  have  been  invented, 
with  the  view  of  increasing  the  motion  of  the  drill, 
of  augmenting  its  power,  and  especially  of  bringing 
it  to  bear  upon  points  inaccessible  to  the  straight  in- 
strument. 

The  use  of  the  burs  and  drills  by  the  hand,  and 
by  means  of  the  various  drill-stocks,  has  been  almost 
wholly  superseded  by  the  introduction  and  use  of  the 
dental  engine. 

This  appliance,  in  a  far  less  perfect  form  than  now, 
was  introduced  to  the  dental  profession  about  the 
year  1870. 

Mr.  Green,  of  Michigan,  first  introduced  the  pneu- 
matic engine ;  succeeding  this,  was  that  denominated 
the  "  Morrison  Engine."  Within  a  short  time  after 
this,  the  suspension  engine  was  devised  and  constructed 
by  Dr.  W.  S.  Elliott, 

This  engine  possesses  some  excellent  qualities.  Its 
steadiness  of  motion,  freedom  from  tremor  or  back- 
lash, and  the  facility  of  use,  are  qualities  that  make  it 
very  valuable  in  these  respects.  When  the  large  dress- 


107 


108 


[INSTRUMENTS   FOR   FILLING. 

Fio.  18. 


ENGINES. 


109 


ing  burs  or  polishing  cones  are  being  used  it  is  superior 
to  any  other. 

The  illustration  on  page  107  (Fig.  17)  gives  a  cor- 
rect idea  of  the  machine. 

Various  other  modifications  of  dental  engines  have 
from  time  to  time  been  presented,  a  description  of 
which  is  unnecessary  here.  That  improved  by,  and 
bearing  the  name  of  S.  S.  White,  is  at  present  very 
popular ;  it  has  now  the  most  prominent  position  be- 
fore the  profession;  other  modifications,  however,  are 
highly  esteemed  by  many.  It  is  well  rejDresented  by 
the  illustration  on  page  108  (Fig.  18). 

This  engine  certainly  possesses  many  desirable 
qualities.      The  facility  of  movement  and  adaptation 


Fig.  19. 


afforded  by  the  flexible  cable,  and  the  hand-piece,  seem 
to  be  about  all  that  can  be  desired.  The  mode  of  at- 
tachment to  and  retention  of  the  drills  and  other  ac- 


110 


INSTRUMENTS    FOR   FILLING. 


cessories  by  the  hand-piece,  leaves  little  or  nothing 
more  to  be  desired  in  that  direction. 

Attachments  are  made  to  the  hand-piece  by  which 
drills  are  operated  at  a  right  angle  with  the  shaft,  and 
also  at  an  acute  angle,  or  with  a  backward  inclina- 
tion to  almost  forty-five  degrees.  They  are  shown  in 
Fig.  19. 

Some  description  and  illustration  of  the  instruments 
and  appliances  used  with  the  engine  might  appro- 
priately be  given  here,  but  so  numerous  have  they  be- 
come that  it  is  impracticable  to  give  more  than  a  rep- 
resentation of  each  class. 

Fig.  20. 


Fig.  20  presents  illustrations  of  the  spherical  and 
wheel  burs,  three  sizes.  Of  each  class  of  burs  there 
should  be  eight  or  ten  sizes ;  it  would  also  be  well  to 
have  two  or  three  grades,  as  respects  fineness  of  cut ; 
the  coarser  will  serve  for  rapid  work,  and  the  finer  for 
the  smooth  and  more  perfect  work. 

This  variation  may  with  propriety  pertain  to  all 
forms  of  burs  used  upon  the  teeth,  and  those  used  for 
dressing  fillings  as  well. 


BURS. 


Ill 


Fig.  21  shows  the  cone  and  the  inverted  cone- 
shaped  burs ;  about  the  same  variety  in  number  and 
size  will  be  required  as  of  the  spherical. 

Fig.  21. 


In  Fig.  22   are  presented  the  fissure  burs,  square 
and  pointed. 


Fig.  22. 


In  Fig.  23  are  shown  the   bud-shaped  and  oval 
burs. 

Fig.  23. 


In  the    following  illustration    are  shown  the  flex- 


112 


[NSTRUMENT8    FOR    FILLING. 


ible    burs    »nd    drills    for   operations    in    canals   of 
roots. 

Fig.  24. 


Fig.  25  shows  the  spear,  the  square  edge,  and  the 
spade-shaped  drills,  all  flat ;  and  the  twisted  drill. 


Fig.  25. 


The  burs  and  drills  here  presented  embrace  all  the 
principles  that  have  been  employed  in  the  ordinary 
operations  upon  the  natural  teeth. 

Of  the  plug-dressing  burs  a  large  variety  is  made  ; 
nearly  the  same  general  forms  have  been  adopted  as 
in  those  for  operating  in  cavities  of  decay. 


DRILLS. 


113 


The  following  illustration  gives  the  most  common 
forms. 


Fig.  26. 


In  the  following  is  shown   a  set  of  burnishers  for 


finishing  fillings. 


Fig.  27. 


The  following  illustrates  a  set  of  corundum  points, 
cones  and  disks  for  finishing  fillings. 


Fig.  28. 


AJboul  the  same  forma  and  sizes  of  points  for  fin- 
ishing are  made  of  Arkansas,  Scotch,  and  Hindostan 
stones.     TImsc  are  all  valuable,  and  should  always  be 


114 


[NSTRUMENTS    FOB    PILLING. 


at  hand,  and  a  sufficient  variety  of  sizes  to  meet  all 
cases.     They  are  shown  by  Fig.  29. 


EXCAVATOES. 

Of  the  small  cutting-instruments  for  opening  and 
forming  cavities,  and  removing  decay  from  them, 
there  is  a  great  variety,  though  a  few  general  forms 
comprise  the  whole.  Until  within  comparatively  a 
short  time,  there  has  been  no  very  systematic  arrange- 
ment of  these  instruments,  such  as  the  convenience 
both  of  the  profession  and  the  manufacturers  of  dental 
instruments  would  seem  to  dictate.  In  a  classification 
that  we  have  adopted  and  found  very  convenient, 
they  are  arranged  by  numbers,  the  most  simple  being 
placed  under  the  first,  and  under  each  successive  num- 
ber a  more  complicated  form.  All  the  varieties  are 
embraced  in  twelve  numbers,  which  are  represented  in 
Fig.  30.  These  varieties  are  discriminated  by  the 
forms  of  the  points,  and  their  position  on  the  shaft  to 
which  they  are  attached,  and  not  by  any  curve  which 
the  shaft  may  have  at  any  distance  from  the  point. 


EXCAVATORS. 


115 


No.  1  has  simply  a  flat  point  slightly  curved,  with 
a  round  edge  transverse  to  the  shaft.  Four  sizes  will 
be  sufficient  for  ordinary  purposes. 


Fro.  30. 


No.  2  haa  a  flat  point  with  a  short  curve,  bringing 
the  point  to  a  right  angle  with  the  shaft;  the  edge  is 
transverse.  This  differs  from  No.  I  in  having  the 
curve  more  Bhorl  and  abrupt,  and  the  edge  more 
nearly  square.  Of  these  there  should  be  live  sizes, 
with  some  variety  of  form. 

No.  3  has  a  flat  point  with  a  square  transverse  ed 


31(5  [INSTRUMENTS    FOB    PILLING. 

which  rises  at  a  right  angle  from  the  shaft ;  the  blade 
being  from  one  to  two  lines  in  length.     Five  sizes. 

No.  4  has  a  flat  point,  curved  so  as  to  be  at  a  right 
angle  with  the  shaft;  the  blade,  from  the  centre  of 
the  curve  to  the  edge,  being  from  one  to  two  lines, 
and  the  edge  straight.     Four  sizes. 

In  each  of  the  foregoing  the  edges  should  expand 
slightly  in  width. 

No.  5  has  a  flat  point  with  a  square  edge,  which  is 
parallel  with  the  shaft,  and  rises  at  a  right  angle 
from  it.  The  blade  is  from  one-half  to  two  and  a  half 
lines  in  length,  and  from  one-half  to  one  line  in  width, 
with  no  expansion  at  the  edge.  Six  sizes,  with  some 
variety  of  form. 

No.  0  and  7  are  right  and  left  excavators,  with  flat 
points  and  double  curves;  the  first  curve  being  at  an 
angle  of  about  twenty  degrees,  and  the  other  lateral, 
right  and  left,  reaching  from  the  beginning  of  the 
first  curve  to  the  point  The  length  of  blade  is  from 
one  to  three  lines.     Four  sizes. 

No.  8  has  a  crescent-shaped  point,  the  blade  rising 
by  a  small  attachment  from  the  shaft,  and  making  a 
right  angle  with  it.  The  edge  is  a  regular  curve,  de- 
scribing about  two-fifths  of  a  circle,  and  is  parallel 
with  the  handle.  The  point  should  be  perfectly 
formed.     Six  sizes. 

No.  9.  The  form  of  the  point  is  the  same  as  in  No. 
8,  the  difference  being  in  the  position  of  the  blade,  the 


EXCAVATORS.  117 

edo-e  of  which  is  transverse  to  the  shaft,  and  rises 
from  it  at  an  angle  of  one  hundred  and  thirty  degrees. 
Six  sizes. 

In  No.  10  the  point  has  the  same  shape  as  in  Nos. 
8  and  9.  The  cutting  edge  is  transverse  to  the  shaft, 
and  rises  by  a  small  neck  at  a  right  angle  from  it. 
Six  sizes. 

Such  are  the  most  important  forms  of  excavators, 
though  modifications  will  be  required  for  particular 
cases.  "While  Xos.  8,  9,  and  10  are  not  in  extensive 
use,  a  few  operators  have  used  them  for  some  years, 
and  prize  them  very  highly.  In  many  difficult  cases 
they  are  far  more  applicable  than  any  other  instru- 
ment we  have.  For  instance,  in  the  formation  of  the 
cervical  wall  of  a  proximate  cavity  in  any  of  the  teeth, 
but  particularly  in  the  superior  bicuspids  and  molars, 
there  is  no  other  instrument  so  applicable  and  efficient 
as  No.  9  ;  with  it,  that  part  of  the  cavity,  so  frequently 
neglected,  is  just  as  easily  formed  as  any  other. 

Cases  will  occasionally  be  presented  in  which  some 
curvature  of  the  shaft  of  the  instrument  will  be  requi- 
site. But  no  more  curve  should  be  given  to  any  in- 
strument than  may  be  absolutely  necessary,,  for  it  is 
impossible  to  manipulate  with  the  same  precision  and 
delicacy  with  curved  as  with  straight  instruments.  The 
degree  of  curve  necessary  in  any  given  case  will  be 
determined  by  the  position  of  the  decay  on  the  tooth, 
and  the  locution  of  the  latter  in  the  mouth. 


118  [NSTRUMENT8    FOB    PILLING. 

The  diamond  point,  as  it  is  familiarly  called,  is  a 
modification  of  No.  3,  varying  from  it  in  that  it  has  a 
sharp  point  instead  of  a  square  edge,  and  is  three-sided 
from  shaft  to  point,  each  angle  being  a  cutting  edge. 
Tli is  instrument  is  especially  valuable  for  forming 
grooves  or  furrows  within  cavities,  and  for  dressing 
the  borders. 

After  being  much  reduced  by  use,  it  may  still  be 
kept  in  form,  and  sharp,  and  used  as  a  drill  for  mak- 
ing under-cuttings,  for  which  it  is  very  efficient.  No. 
11  represents  this  instrument. 

A  modification  of  No.  9,  commonly  known  as  the 
scoop  or  spoon-shaped  instrument,  is  much  used.  The 
sharp  corners  of  No.  9  are  removed  in  this  instrument. 
It  is  shown  in  No.  12. 

Since  the  issue  of  the  second  edition  of  this  work, 
efforts  have  been  made  by  several  members  of  the  pro- 
fession to  arrange  and  systematize  excavators  into  sets, 
that  should  embrace  every  desirable  form  and  size. 
No  one  has  as  yet  succeeded  in  producing  that  which 
meets  the  views  of  all  operators. 

There  is,  perhaps,  now  more  diversity  of  opinion  and 
practice  in  reference  to  the  use  of  hand  excavators,  in 
the  preparation  of  teeth  for  filling,  than  ever  before, 
from  the  fact  that  a  great  diversity  of  practice  exists 
in  reference  to  the  use  of  the  dental  engine  and  its  ac- 
cessories for  this  purpose;  some  using  these  almost 
exclusively  in  the  preparation  of  cavities ;  others  for 


EXCAVATORS. 


119 


this  purpose  making  far  less  use  of  the  engine,  and 
more  use  of  the  hand  excavators,  claiming  that  with 
the  latter  much  more  precise  and  definite  execution 
can  be  attained. 

Fig.  31  presents  an  arrangement  of  excavators  by 
Dr.  I.  J.  Wetherbee,  very  good  indeed  so  far  as  they 


Fig.  31. 

n      a 


extend,  and  perhaps  in  the  majority  of  cases  they  would 
quite  suffice. 

Of  the  Manufacture  of  Excavators. — For  making 
these  instruments,  the  best  cast-steel  wire,  No.  8,  should 
be  selected.  This  should  be  forged  down  so  as  to  leave 
tin-  end  large  enough  to  form  the  intended  point.  Nos. 
1  to  6  inclusive,  Fig.  30,  may  be  formed  by  forging, 
and  afterward  dressed  up  with  the  file.  No.  8  to  12, 
Inclusive,  should  be  formed  by  the  files  out  of  a  hull* 
left  from  tin-  forge;  for  this  purpose  differenl  forms 
and  Bizee  of  files  will  be  required,  in  order  definitely 


120  [NSTEUMENTS    FOB    PILLING. 

to  shape  all  the  angles  and  points.  In  heating  steel, 
either  for  forging  or  tempering,  a  full  red  heat  should 
in  no  case  be  exceeded,  since  a  higher  degree  than  this 
injures  it.  After  the  points  are  formed,  and  made 
smooth  with  an  emery  stick  or  wheel,  they  are  to  be 
tempered ;  this  is  a  delicate  process,  requiring  much 
experience  and  care.  The  point  should  be  wanned  in 
a  spirit-lamp,  and  then  covered  with  soap,  to  prevent 
oxidation  and  scaling.  The  instrument  is  then  brought 
to  a  full  red  heat  with  a  spirit-lamp,  blow-pipe,  and 
charcoal,  and  suddenly  plunged  into  a  cake  of  soap 
or  cold  water,  when  it  will  j>resent  a  silvery  white- 
ness ;  the  steel  in  this  condition  is  extremely  hard  and 
friable.  It  should  then  be  polished  with  an  emery- 
stick  or  oil-stone,  and  drawn  down  to  the  proper  tem- 
per. This  tempering  is  accomplished  by  placing  the 
edge  of  the  instrument  on  a  piece  of  cold  polished  steel 
or  iron,  and  its  shaft  placed  near  or  in  the  flame  of  a 
small  spirit-lamp,  and  retaining  it  there  till  it  changes 
to  a  deep  blue  color,  graduated  down  to  the  point  in  a 
deep  straw  or  copper  hue.  The  purpose  in  holding  the 
point  of  the  instrument  on  a  piece  of  cold  polished  iron 
or  steel  is,  that  the  heat  there  may  be  subject  to  com- 
plete control.  The  precise  shade  will  be  governed  by 
the  purpose  for  which  the  instrument  is  to  be  used  ;  if 
for  a  drill,  the  edge  or  point  should  be  of  a  light  straw 
color ;  indeed,  some  operators  prefer  to  have  them 
scarcely  changed  at  the  cutting  edge,  while  excavators 


INSTRUMENTS    FOR    FILLING.  121 

and  chisels  should  be  brought  to  a  deep  straw  or  cop- 
per color  ;  this  will  be  modified,  however,  by  the  man- 
ner of  working  the  steel,  and  its  quality.  Skilfully 
hammering  steel  at  a  low  heat,  below  a  red,  gives  an 
improved  texture,  and  adds  much  to  its  quality  for  a 
fine  cutting  instrument.  Indeed,  some  assert  that  those 
instruments  that  can  be  forged  to  nearly  their  proper 
shape,  can  be  as  well,  if  not  better,  tendered  by  the 
hammer  as  by  any  other  means. 

The  instrument  is  then  to  be  polished  by  the  emery- 
wheel  and  dressed  up  with  the  oil-stone.  Of  the  va- 
rious methods  of  tempering  the  foregoing  is  equal  in 
efficiency,  and  in  convenience  superior  to  any  other. 


Filling  Instruments. 

For  introducing  and  consolidating  fillings,  a  great 
variety  of  instruments  is  in  use.  In  every  form  in 
which  gold  is  employed  for  filling  teeth  the  pliers  are 
required  for  taking  up  the  pieces  and  placing  them  in 
the  proper  position  in  the  cavity  ;  in  cylinder  or  block- 
filling  they  are  indispensable.  These  instruments  are 
made  of  different  forms  and  sizes — of  such  forms  as 
to  facilitate  access  to  cavities  inconvenieutly  located ; 
of  different  sizes  to  accommodate  cavities  of  various 
r;i)ia<-iti<'-.  K<>r  a  Large  majority  of  cases  they  require 
a  slight  curve,  about  half  an  inch  from  the  point;  for 


1 22 


[NSTRUMENTS    FOE    PILLING. 


some  cases,  however,  the  curve  should  be  a  right-angle. 
(Fig.  32.) 

The  points  of  the  pliers,  when  closed,  should  present 
such  a  form  as  to  be  used,  to  some  extent  at  Least,  for 
consolidating  the  gold.  This  instrument  should  be 
about  five  inches  long. 

The  forms  of  condensing  instruments  may  be  mul- 
tiplied to  an  almost  indefinite  extent.     They  are  all, 


however,  but  modifications  of  two  or  three  general 
principles.  The  particular  form  of  the  plugging- 
point  will  he  determined  by  the  form  in  which  the 
gold  is  used.  With  non-cohesive  gold,  small  square, 
or  round  sharp  points  of  various  curves  are  required. 
These  points  are  easily  kept  in  proper  condition,  and 
in  some  instances  are  used  for  years  without  change  or 
repair. 

A  favorite  method  of  filling  with  non-cohesive  gold, 
by  many  excellent  operators,  is  in  the  use  of  cylinders 
or  blocks ;   for    this    method    instruments   especially 


INSTRUMENTS    FOR    FILLING. 


123 


adapted  have  been  devised,  which  the  following  cut 
represents  : 


Fig.  33. 


Fig.  84  is  square  from  the  curve  to  the  point,  and 
i>  used  in  the  same  manner,  and  for  nearly  the  same 
purpose,  as  Fig.  33. 


Fig.  34 


For  introducing  and  condensing  key-blocks — those 
intended  to  bind  the  filling  in  place— Fig.  35  is  the 
proper  form : 


Fio.  35. 


:24 


tNSTRUMENTS   FOR   FELLING. 


Figs.  36  and  37  are  designed  for  condensing  the 
surface  of  crown  fillings,  in  the  superior  and  inferior 
molars  respectively . 


Fig.  36. 


Fig.  37. 


^^ 


The  instruments  represented  by  the  following  are 
for  condensing  the  surfaces  of  proximate  fillings. 

Fig.  38. 


Fig.  39  represents  round  right  and  left  condensing 
points  to  be  used  in  filling  proximate  cavities. 

Fig.  39. 


INSTRUMENTS    FOR    FILLING. 


125 


Fiss.  40  and  41  are  flat,  right  and  left  condensing 
points,  for  same  cavities  as  Fig.  39. 


Fig.  40. 


Fir;.  41. 


The  following  cuts  represent  a  set  of  filling  in- 
struments devised  and  arranged  by  Dr.  W.  G.  Red- 
man. 

They  constitute  probably  the  most  complete  set 
made,  for  filling  with  blocks  or  cylinders  for  non-co- 
besive  gold.  They  are  made  with  ebony  or  ivory 
handles,  and  are  used  with  hand  force  only. 

With  cohesive  gold  in  any  of  its  forms,  the  points 
all  require  to  be  serrated.  There  are  three  or  four 
varieties  of  these,  which  it  will  he  proper  to  describe. 
Tne  lir-t  is  square,  and  slightly  bent  about  half  an 
inch  from  the  end,  which  is  formed  into  four  or  six 
definite  sharp  points  with  the  edge  of  a  thin  file.      Of 

this  variety  there  should  be  aboul  five  sizes,  the  largest 


12G 


IN- l  RUMEXTS    FOB    FILLING. 


entering  No.  L8  of  Stubb's  gauge,  and  the  smallesl  No. 
38.     The  former  should  have  six  points,  and  the  other 

Fig.  42. 


((•  ji   (Tl    s--a    n 

r 


©        • 


two  sizes  four.   (Fig.  43.)       The  cuts  upon  these  are 
made  directly  across  the  end.     In  another  variety  the 

Fig.  43. 


INSTRUMENTS    FOR    FILLING. 


127 


end  is  rounded,  and  the  file  placed  upon  it  at  an  acute 
angle  with  the  side  of  the  instrument,  and  the  cuts, 
three  in  number,  are  made  to  the  centre  of  the  point, 


Fiu.  44. 


which  thus  becomes  triangular,  or  three-pointed,  from 
a  common  centre.  (Fig.  45.)  Four  or  five  sizes  of 
these  may  be  employed,  ranging  from  18  to  26,  Stubb's 

Fig.  45. 


gauge.  A  thin  double  point,  from  26  to  28,  is  in 
many  cases  very  valuable.  Instruments  with  a  con- 
densing surface  on  the  side,  instead  of  the  end,  will 


Fig.  46. 


frequently  be  required  I'm  Idling  lateral  cavities; 
these  may  be  denominated  lateral  pluggers.  (Fig. 
46.)     This  condensing  surface  should  also  be  serrated, 


128 


[NSTRUMENTS    FOR    PILLING. 


as  already  described.  An  instrument  square  al  the 
point,  ranging  from  18  to  22,  and  cut  upon  the  end 
by  passing  it  along  the  cuts  of  a  file  both  ways,  thus 
making  a  largo  number  of  small  serrations  at  right 
angles  across  the  point,  is  valuable  for  consolidating 
the  surface  of  a  plug.  (Fig.  47.)  Operating  super- 
ficially on   the  principle  of  the  more  deeply  serrated 

Fig.  47. 


instruments,  it  yet  leaves  the  surface  free  from  deep 
pits  or  indentations,  and  still  so  impressed  that  it  will 
receive  and  retain  more  gold,  if  necessary,  as  it  would 
not  do  if  the  end  of  the  instrument  was  perfectly 
smooth.  A  smooth-pointed  instrument  or  burnisher 
may  he  applied  after  all  the  gold  has  been  added. 

Fig.  48. 


Fig.  48  is  an  instrument  with  file-cut  sides.  It  is 
valuable  for  dressing  down  proximate  fillings  to  a  uni- 
form surface.     There  may  be  two,  one  with  the  sides 


INSTRUMENTS    FOR    FILLING. 


129 


parallel  with  the  shaft,  and  one  with  its  sides  trans- 
verse to  the  shaft;  it  terminates  in  a  sharp  edge. 

In  considering  this  subject  thus  far,  the  aim  has 
been  to  present  the  principles  that  should  be  embraced 
by  instruments  for  properly  filling  the  various  classes 
of  cavities  that  are  presented. 

Within  the  last  ten  years  great  changes  and  im- 
provements have  been  made  in  this  class  of  instru- 
ments, especially  with  reference  to  classifying  and  sys- 
tematizing them. 

It  will  be  seen  by  the  accompanying  illustrations 
that  considerable  attention  has  been  given  in  this  di- 
rection. Fig.  49  presents  Dr.  W.  H.  Atkinson's 
"  Omega  "  pluggers. 

Those  who  have  become  familiar  with  these  instru- 
ments prize  tli<-m  very  highly. 

I))'.  K.  Abbott's  sel  of  pluggers  are  also  regarded 

highly  by  many.      (Shown  in   Fig.  oO.) 


130 


INSTRUMENTS    FOR    FILLING. 
Fir;.  50  B. 


This  cut  (Fig.  51)  represents  Dr.  Lewis  Jack's 
"Matrix"  pluggers.  The.y  are  designed  for  and  are 
well  adapted  to  operations  in  which  the  matrix  is  re- 
quired. 


Fig.  51  b. 


Fig.  52  represents  Dr.  K.  W.  Varney's  set  of 
pluggers.  These  were  among  the  first  regularly 
arranged  sets  of  pluggers,  and,  in  some  respects, 
superior  to  any  that  preceded  them,  and  became  very 
popular. 

Fig.  53  represents  Dr.  C.  R.  Butler's  set  of  pluggers, 


Fig.  52  a. 


\     \ 


INSTRUMENTS    FOR   FILLING. 
Fig.  52  b. 

ft  f  C f  (fH  / 


131 

Fig.  53  a. 


different  in  some  respects  from  all  the  others,  but  ex- 
cellent nevertheless,  and  better  adapted  for  some  cases. 


Fig.  53  b. 


Fig.  54  shows  in  many  important  respects  the  most 
perfect  set  of  plugging  instruments  ever  made.  They 
are  tin-  result  of  long  and  patient  investigation  ;  they 
will  be  at  once  recognized  as  the  work  of  Dr.  Corydon 
Palmer. 

Tin-  following  cut  illustrates  them  as  well  as  the 
engraver's  art  can  do  it. 


132 


[NSTJRUMENT8    FOR   FILLING. 
Fig.  54. 


20       21        22      23      24-       25       26       27        28         29         30 


INSTRUMENTS   FOR    FILLING.  133 

A  minute  description  of  each,  with  the  directions  for 
its  use,  is  given  in  section  B,  in  the  Appendix. 

In  many  cases,  a  valuable  instrument  for  consoli- 
dating is  the  plugging-forceps,  the  general  form  of 
which,  except  the  beaks,  is  that  of  the  ordinary  straight 
extracting  forceps.  The  beaks  are  formed  into  sockets 
for  the  reception  of  the  plugging-points,  one  of  which 
is  of  the  common  construction,  but  the  other  has  a 
broad  flat  surface  to  rest  against  the  tooth.  (Fig.  55.) 
This  instrument  is  applicable  only  in  certain  cases, 
principally  in  filling  proximate  cavities.     Its  main  ad- 

Fig.  55. 


vantage  consists  in  its  capability  of  applying  a  strong 
pressure  upon  the  filling  without  affecting  the  socket. 
Manipulation  with  it  is  less  rapid  and  definite  than 
with  the  ordinary  condensing  instruments;  and  with 
it,  too,  there  is  much  danger  of  fracturing  friable 
teeth. 

There  has  been,  within  the  last  few  years,  very 
great  improvement  made  in  the  serrated  plugging 
instruments — those  employed  for  working  cohesive 
foil.  It  consists  in  delicacy  and  perfection  of  form, 
;i  Large  addition  to  the  variety,  and  a  good  systematic 
arrangement. 


134 


IN-TIIUMENTS    FOR    FILLING. 


These  instruments  are  now  manufactured  and  put 
up  in  sets,  embracing  every  requisite  form,  numbering 
from  forty  to  sixty;  this  includes  surface  condensers 
and  burnishers. 

The  profession  is  largely  indebted  to  the  efforts 
of  Drs.  Palmer,  Atkinson,  and  Abbott,  of  New  York, 
for  the  perfection  obtained  in  the  production  of  these 
instruments. 

The  File. 

Of  this  valuable  and  indispensable  instrument  there 
is  a  variety  of  forms  used  by  the  dentist.     The  thin 

Fig.  .56. 


files  (Fig.  5ti)  are  chiefly  applicable  to  the  anterior ; 
the  thick,  heavy,  knife-shaped  (Fig.  57)  to  the  pos- 
terior teeth.  The  latter,  to  facilitate  their  approach 
to  the  points  operated  upon,  have  various  curves,  some 
single,  others  double,  the  double  being  preferable,  since 
they  bring  the  handle  of  the  instrument  on  a  line 
with  its  cutting  edge.  The  cuts  upon  this  instrument, 
too,  are  quite  various ;  in  size,  ranging  from  very 
coarse  to  very  fine,  and  in  obliquity  from  a  line  almost 


THE    FILE. 


135 


at  right  angles  across  it  to  one  at  an  angle  of  forty-five 
degrees.  These  cuts,  too,  are  either  single  or  double, 
the  double  being  those  made  across  one  another.  The 
single,  however,  are   preferable  for  all  operations  on 


lhi—i 


Fig.  57. 


11 iiiiiiiiiaiiiiiittii«iiiiiiiiiiiiiiE~i: ..i.iiiiiiiiiiiil) 


the  teeth,  and  the  more  oblique  are  to  be  recommended, 
since  they  cause  less  of  that  jarring  unpleasant  sensa- 
tion to  the  patient. 


Fig.  58. 


There  are  in  use  various  forms  of  file-carriers,  two 
of  which  are  represented  in  Figs.  58  and  59.  Fig. 
59,  denominated  "  Redman's  file-carrier,"  is  an  excel- 
lent instrument,  one  principal  advantage  of  which 
consists  in  the  facility  with  which  it  may  be  changed 
from  the  one  side  to  the  other.  Files  are  made 
adapted  to  the  instrument,  the  chief  advantage  of 
which    [a  that   it   retains  Liu;  file  much    more  firmly 


136 


[X8TRUMENTS    Foil    FILLING. 


than  it  can  be  held  in  the  fingers.     These  carriers  ar< 
made,  with  a  variety  of  curves  to  accommodate  dif- 

Fig.  59. 


ferent   positions.     There   is   also   a   great  variety  of 
small   file-point   instruments   for  dressing  down  fill— 


Fig.  60. 


ings,  the  more  important  of  which  are  represented  in 


Fig.  60. 


THE    FILE.  137 

The  Use  of  the  File. — When  a  separation  of  the 
teeth  is  requisite,  preparatory  to  filling,  it  is  fre- 
quently accomplished,  either  in  whole  or  in  part, 
with  the  file,  though  now  far  less  frequently  than  for- 
merly. Principally,  in  such  a  case,  its  use  is  re- 
stricted to  finishing  and  smoothing,  after  the  greater 
portion  of  the  work  has-  been  done  with  die  heavy 
cutting  instrument,  or,  in  dressing  off  the  thin  at- 
tenuated edges.  The  file  is  valuable  for  removing 
superficial  decay,  being  called  into  frequent  requisi- 
tion in  caries  of  this  kind.  It  is  employed  to  dress 
off  roots  preparatory  to  the  insertion  of  pivot  teeth, 
for  which  purpose  it  is  required  to  be  of  a  round 
or  half-round  form.  It  is  used  for  dressing  off  sharp 
portions  or  edges  of  the  teeth  that  may  be  injurious 
to  the  soft  parts,  and,  in  'some  cases,  for  dressing 
down  a  tooth  that  is  elongated.  In  finishing  many 
fillings  it  is  almost  indispensable.  It  was  formerly 
used  to  some  extent  in  the  treatment  of  irregularity, 
but  for  this  purpose  it  has  been  abandoned. 

Mode  of  Using  the  File. — The  patient  should  be  con- 
veniently seated,  with  the  head  on  a  firm  support, 
and  under  the  control  of  the  operator,  who  should 
occupy  a  position  at  the  right  of  the  patient,  in  most 
cases,  so  disposing  the  head  of  the  latter  as  to  give 
free  access  to  that  point  which  is  to  be  operated 
upon.  In  manipulating  with  the  file  considerable 
skill   and   delicacy  are   requisite.     It  should  not  be 


138  INSTRUMENTS   FOR   FILLING. 

held  with  a  stiff,  unyielding  grasp,  so  as  to  catch  and 
jar,  but  should  be  applied  with  a  gentle  pressure, 
and  drawn  across  the  tooth  with  a  free  and  flexible 
motion.  It  should  be  frequently  moistened,  and  not 
allowed  to  clog  with  the  filings,  being  kept  free  of 
these  by  repeated  applications  of  the  brush.  A  sharp, 
new  file,  with  a  quick,  light  movement,  will  cut  far 
more  rapidly,  and  less  unpleasantly  to  the  patient, 
than  one  that  is  dull  or  clogged  applied  with  a  heavy 
pressure.  If  the  tooth  bone  is  sensitive,  the  file 
should  be  moistened  in  warm  water.  For  cleansing 
files,  when  clogsed  with  dentine,  the  wire  brush  in 
common  use  is  quite  efficient.  Every  operator  should 
have  one  at  hand.  The  form  of  a  file  may  be  changed 
by  drawing  the  temper,  bending  it  as  desired,  and 
then  retempering  it.  It  is  better,  however,  to  have 
them  made  of  the  proper  form  at  first. 

The  teeth,  while  being  filed,  should  be  supported 
by  the  fingers,  or  by  an  instrument  for  the  purpose; 
or  a  cork  or  piece  of  soft  wood  may  be  inserted  be- 
tween the  tooth  being  filed  and  the  teeth  of  the  op- 
posing jaw,  and  the  pressure  thus  used  as  a  support. 
The  tooth  being  sustained  in  this  manner,  there  is 
less  jarring  experienced  by  the  patient,  and  less  lia- 
bility to  produce  irritation  of  the  periosteum.  When 
filing  the  anterior  teeth  it  is  generally  better  to  hold 
the  file  in  the  fingers.  For  filing  the  incisors  and 
cuspids   a   thin,  bevel-edged  file   is  to  be  preferred. 


THE    FILE.  139 

In  dressing  a  tooth  with  a  file,  the  last  that  is  used 
should  be  a  fine  one,  after  the  application  of  which 
the  surface  operated  upon  should  be  made  as  smooth 
as  possible  with  a  stone  and  burnisher,  or  with  a  buff 
and  rotten-stone. 

In  separating  teeth  with  a  file,  where  but  one  is 
decayed,  care  should  be  taken  not  to  cut  the  sound 
one.  For  this  purpose  it  will  usually  be  necessary 
to  have  a  safe-sided  file,  one  side  smooth  to  present  to 
the  sound  tooth;  and,  even  then,  the  cutting  edge 
should  be  somewhat  bevelled  from  the  safe  side,  that 
the  sharp  angle  of  that  edge  may  not  rasp  the  sound 
tooth;  in  no  case  of  this  kind  should  a  square-edged 
file  be  used.  In  cases  in  which  it  is  necessary  to 
file  teeth  that  are  somewhat  loose  in  the  sockets,  and 
whose  periosteum  is  in  a  state  of  irritation,  to  build 
up  a  wall  of  plaster  of  Paris  round  them,  permitting 
it  to  harden,  will  very  much  facilitate  the  operation. 
Perhaps  a  preferable  method,  in  some  respects,  for 
accomplishing  the  same  object,  is  to  mould  softened 
gutta-percha  to  the  tooth  and  the  parts  about  it;  after 
it  has  become  hard,  hold  it  firmly  in  place  while  the 
filing  is  accomplished.  Or,  binding  three  or  four 
teeth,  including  the  loose  one,  with  fine  silver  wire, 
the  loose  tooth  will  be  held  firmly.  Either  of  these 
methods  will  be  found  valuable  in  cases  where  it  is 
necessary  to  dress  off  a  considerable  portion  from  the 


140  [N8TRUMENT8   FOB    PILLING. 

end  of  one  or  more  of  the  inferior  front  teeth.  There 
are  some  teeth  upon  which  the  use  of  the  file  is 
hardly  admissible;  as,  for  instance,  those  which  are 
highly  predisposed  to  inflammation  and  sensitiveness 
of  the  dentine.  The  teeth  of  young  persons,  being 
often  of  this  character,  should  be  filed  with  great 
caution,  but,  in  general,  those  of  adults  may  be 
filed  if  properly  done,  with  more  freedom.  The  file 
should  not  be  used  upon  the  teeth  when  the  peri- 
osteum, the  gums,  or  the  mucous  membrane  is  dis- 
eased, or  strongly  predisposed  to  such  a  condition. 
It  should  never  be  used  for  the  correction  of  irregu- 
larity of  the  teeth,  especially  when  they  are  sound  ; 
nor  should  it  be  employed  to  separate  sound  teeth 
to  introduce  clasps. 

Filing  the  teeth  is  an  operation  against  which 
there  has  been  and  still  is  much  prejudice,  though 
without  sufficient  cause.  Whatever  injury  results 
from  this  operation  is  from  the  imperfect  manner  in 
which  it  is  performed,  and  from  subsequent  neglect 
of  the  tooth  which  has  been  subjected  to  it.  A  tooth 
skilfully  treated  with  this  instrument,  and  properly 
cared  for  afterward,  will  not  be  more  liable  to  decay 
at  the  point  operated  upon  than  at  any  other  where 
the  dentine  may  be  exposed. 

Since  the  introduction  of  the  disks  to  be  used  with 
the  engine,  and  especially  the  diamond  disks,  the  de- 


THE    FILE.  Ml 

mand  for  the  file  for  separating  and  dressing  the 
teeth  has  become  very  greatly  diminished,  and,  in 
the  practice  of  some,  almost  wholly  superseded.  It 
is  well,  however,  that  the  student  should  learn  the 
use  of  the  file. 


CHAPTER  V. 


SEPARATION    OF    THE    TEETH. 


In  most  cases  of  proximate  decay,  the  teeth,  before 
the  operation  of  filling  can  be  performed,  must  be 
separated ;  though  cases  are  not  un frequent  where 
the  space  between  them  is  sufficient  to  admit  of  free 
manipulation  without  this  preliminary.  An  imper- 
fect accomplishment  of  this  first  step  in  the  process 
of  filling  is  a  prolific  source  of  the  many  failures,  in 
proximate  cavities,  to  attain  to  efficient  and  durable 
results  ;  for  unless  this  step  be  thoroughly  performed, 
so  as  to  make  room  for  the  free  introduction  and 
use  of  the  various  instruments  requisite,  no  part  of 
the  work  can  be  complete.  Though  the  most  com- 
mon object  for  which  teeth  are  separated  is  to  ob- 
tain space  for  free  manipulation  with  the  instru- 
ments in  filling,  yet  there  are  various  other  objects 
for  which  they  have  been  separated,  but  many  of 
which  are  now  better  accomplished  by  other  means. 
It  is  sometimes  necessary  to  cut  away  more  than 
would  otherwise  be  requisite,  in  order  to  remove  thin, 
friable  edges  of  the  cavity,  so  as  to  obtain  sufficiently 
firm  borders.  Teeth  are  in  some  instances  separated 
for  the  introduction  of  clasps — a  practice  always  to 


SEPAKATIOX    OF   THE   TEETH.  143 

be  deprecated,  since  it  usually  proves  injurious. 
Though  the  practice  was  once  very  common,  yet 
most  if  not  all  the  best  operators  have  now,  with 
good  reason,  abandoned  it  altogether.  At  one  time, 
too,  it  was  a  general  practice  to  separate  the  teeth 
with  the  file  to  relieve  a  crowded  condition  ;  but  this, 
also,  has  been  superseded  by  better  processes. 

There  are  two  methods  of  separating  the  teeth  : 
the  one,  to  cut  away  a  portion  ;  the  other,  to  force 
apart  by  pressure,  acting  upon  one  or  more  teeth,  as 
the  circumstances  admit.  Formerly,  all  separations 
were  effected  by  the  file,  and  this  of  very  crude 
form  and  cut,  b}T  which  instrument,  especially  in 
unfavorable  cases,  much  injury  has  been  done. 
Though  the  file  is  a  valuable  instrument,  yet,  for  re- 
moval of  any  considerable  portion  of  dentine,  it  is 
not  to  be  recommended.  Its  action  upon  sensitive 
dentine  is  exceedingly  painful,  besides  being  tedious 
and  wearisome  to  the  patient  and  operator;  it  is  also 
liable  to  irritate  the  periosteum,  and  to  increase  in- 
flammation. When  a  separation  is  to  be  made  that 
requires  the  removal  of  a  considerable  portion  of  the 
tooth,  the  chisel,  or  cutting  instruments,  illustrated 
on  pages  100  and  101,  are  to  be  preferred.  These3 
if  of  the  proper  form  and  temper,  and  in  good  condi- 
tion, are  very  efficient  for  the  purpose,  performing 
the  work  far  more  rapidly  than  the  file,  and  i\w  loss 
unpleasantly  to  the   patient.     They  effect  the   renio- 


Ill  SEPARATION  OF  THE  TEETH. 

val  of  sensitive  dentine  with  but  little  or  no  pain, 
and  without  liability  to  increase  the  inflammation, 
or  to  produce  irritation  or  disease  of  the  periosteum. 
The  force  of  these  instruments  is  sustained  by  the 
entire  attachment  of  the  tooth,  their  pressure  being 
applied  almost  in  a  line  with  its  axis.  Besides,  by 
their  use,  the  contiguous  teeth  are  not  liable  to  in- 
jury, as  by  the  use  of  the  file  they  often  are. 

The  manipulation  with  these  instruments  is  very 
simple.  For  separating  front  teeth,  the  instrument 
is  firmly  grasped  in  the  hand,  the  thumb  placed  on 
the  points  of  the  teeth,  and  the  edge  applied  at  the 
point  or  crown  surface  of  the  tooth  from  which  the 
portion  is  to  be  removed,  and  pressed  gradually  to- 
ward the  gums,  but  not  thrust  into  the  interval  as 
a  wedge  before  it  has  freely  cut  its  way.  In  this 
manner,  as  much  of  the  dentine  as  it  is  desirable  to 
remove  is  cut  off  in  a  few  moments.  This  class  of 
instruments  is  invaluable  for  forming  the  V-shaped 
spaces  between  the  bicuspids  and  the  molars  that 
have  been  popular  with  many  operators,  but  are 
pointedly  condemned  by  others.  It  requires  a  pro- 
longed use  of  the  file  to  make  these  separations 
properly;  and  hence  the  practice  of  attempting  to  fill 
proximate  cavities  without  any  separation  at  all,  by 
operating  through  a  small  opening  at  the  crown  an- 
gle of  the  tooth,  or  a  small  hole  drilled  through  its 
outer  or   inner  portion.      With   the    cutting    instru- 


SEPARATION    OF    THE   TEETH.  145 

merits,  points  upon  the  teeth  that  the  file  cannot 
touch  are  approached  and  operated  upon  with  facility. 
Another  method  of  effecting  the  same  kind  of  sepa- 
ration is,  by  the  use  of  the  corundum  disks,  used 
with  the  dental  engine. 

The  profession  is  indebted  to  'Dr.  Robert  Arthur 
for  devising  and  rendering  practicable  this  very  valu- 
able appliance. 

These  disks,  as  seen  in  the  following  illustration, 
are  made  of  various  forms,  suitable  to  meet  all  cases. 

Fig.  61. 


For  using  the  disks,  carriers  have  been  devised 
and  made.  These  should  possess  three  qualities,  viz., 
ly  adjustment  to  the  hand-piece  of  the  engine  ; 
facility  of  attachment  and  release  of  the  disk;  and 
the  easy  change  of  the  disk  to  any  desired  angle  with 
the  shaft  containing  it.  That  invented  by  Dr.  George 
II.  Cushing   po  these  qualities  in   a  marked 

degree,  and  is  very  effective. 

The  dotted  lines  in  the  figure  show  .the  angular 
range  of  movemenl  of  the  disk  upon  its  shaft. 

For  convenience  and  safety  in  using  the  disk,  a 

lo 


146 


SEPARATION    OF   THE   TEETH. 


shield  or  covering  is  adapted  to  it  that  effectually 
protects  all  parts  except  that  operated  upon. 


Fig.  G2. 


By  means  of  this  instrument,  separations  of  little 
more  than  a  mere  opening  to  the  largest  V-shaped 
space  can  be  readily  made,  and  it  is  claimed  with 

Fig.  63. 


equal  if  not  greater  ease  to  the  patient  than  by  any 
other  method. 

Skill  and  experience  are  required  for  their  facile 
use. 

The  use  of  the  disk  has  largely  superseded  that  of 
the  file  for  separating  teeth. 

But  the  method  of  separation  by  pressure  is  in 
many  cases  to  be  preferred,  especially  in  the  case  of 
anterior  teeth,  whose  natural  form  it  is  important  to 
preserve. 

Till  within  a  comparatively  recent  period,  it  has 
been  the  general  practice   to   separate    by  gradual 


SEPARATION   OF   THE   TEETH.  147 

pressure  ;  and  it  is  even  yet  the  favorite  method  with 
some  operators.  But  in  almost  all  cases  where  sep- 
aration is  to  be  made  by  pressure,  it  can  be  done  at 
once  quite  as  well,  if  not  better,  than  to  prolong  the 
process  through  several  days ;  there  is  economy  of 
time,  and  the  patient  experiences  less  pain,  and  there 
is  less  liability  of  doing  injury  to  the  teeth  or  the 
parts  about  them. 

The  anterior  teeth,  or  those  of  single  roots,  yield 
very  readily  to  a  strong  separating  force,  applied  in 
the  form  of  a  wedge,  notwithstanding  the  teeth  may 
all  be  in  contact  with  each  other ;  though  in  some 
cases  the  teeth  are  so  firmly  set,  and  the  parts  about 
them  so  dense  and  unyielding,  that  it  is  with  great 
difficulty  they  can  be  moved,  without  too  much  vio- 
lence to  the  parts.  It  is  not  generally  practicable  to 
attempt  to  separate  the  molar  teeth  by  pressure. 

The  method  of  effecting  immediate  separation  is 
very  simple ;  it  consists  in  forcing  a  wedge  of  some 
fine-grained  wood  of  medium  resistance — orange  or 
box  wood — between  the  teeth  to  be  separated,  either 
by  pressure  with  the  hand,  or  by  the  blows  of  a  mallet. 
The  wedge  should  be  driven  in  at  the  necks  of  the 
teeth ;  before  this,  however,  a  shield-wedge  should 
be  put  between  the  necks  of  the  teeth  against  the 
septum  of  gum  ;  it  should  be  of  such  form  as  to  re- 
tain its  position  while  the  chief  wedge  is  being  driven 
in ;  and  when  they  are  very  firm,  an  assisting  wedge 


148  SEPARATION    <»F   THE   TEETH. 

may  be  used,  inserted  between  the  points  of  the  teeth, 
and  receiving  strokes  alternately  with  the  other.  The 
assisting  wedge  should  be  of  very  dense  wood,  and 
driven  in  with  great  care,  for  its  leverage  upon  the 
teeth  is  very  great.  When  the  required  space  is  ob- 
tained, the  v  it  the  necks  of  the  teeth  should  be 
driven  tightly  in.  and  the  other  withdrawn.  If  all 
the  teeth  in  the  vicinitj-  of  those  to  be  separated  stand 
in  contact,  the  resistance  to  separation,  whether  by 
immediate  or  gradual  effort,  will  be  greater. 

For  the  introduction  of  the  wedge  a  dental  wedge- 
forceps  has  been  devised  ;  for  forcing  wedges  between 
the  teeth  this  is  preferable  to  the  mallet,  as  the 
unpleasant  blows  of  the  latter  are  avoided;  the  we 
is  introduced  by  gradual  pressure,  the  teeth  are  sup- 
ported by  the  opposing  jaw  of  the  forceps  ;  and  again 
the  wedge  can  be  as  easily  introduced  from  the  inside 
as  the  outside  of  the  arch,  which  in  many  cases  is  a 
great  advantage. 

Two  forms  of  appliances,  denominated  separators, 
invented  by  Dr.  Jarvis,  are  very  valuable  aids  in  the 
separation  of  the  teeth.  The  one  is  for  separating 
the  anterior  and  the  other  the  molar  teeth.  The 
former  is  described  as  consisting  of  two  steel  wedges 
approaching  and  passing  each  other;  being  thus 
drawn  together  by  a  thumb-screw,  making  gradual 
and  prompt  separation  where  it  is  applied. 

Its  operation  is  much  more  acceptable  to  the  patient 


SEPARATION   c  >F   THE   TEETH. 
Fig.  64. 


149 


150  SEPARATION  OF  THE  TEETH. 

than   that  of  the  ordinary  wedge  driven   with  the 

mallet.     It  will  be  found  useful  in  making  room  for 

passing  rubber-dam  between  crowded  teeth.     It  may 

also  be  used  to  advantage  in  connection  with  the 

wedges. 

Fig.  65. 


That  for  the  molars  consists  of  a  properly  formed 
piece  of  steel,  bent  upon  itself,  with  the  ends  formed 
to  fit  the  outer  and  inner  portions  of  the  proximate 
surfaces  of  two  adjoining  crowns. 

These  jaws  are  forced  apart  by  the  action  of  a 
screw,  which  passes  through  one  and  against  the 
other. 

This  form  is  applicable  to  all  the  bicuspids  and 
molars.  It  does  not  touch  the  gum  or  injure  the 
teeth,  neither  does  it  cause  much  pain. 

The  appliance  may  remain  on  the  teeth  in  some 
cases  while  an  operation  is  being  performed ;  other- 
wise a  wooden  wedge  should  be  inserted  between  the 
teeth.     It  is  represented  by  the  following  figure. 

The  rapidit}^  with  which  the  operation  may  pro- 
ceed, and  the  extent  to  which  it  may  be  carried,  will 
be  determined  by  the  tolerance  of  the  parts  to  the 
movement,  which  should  not  be  greater  than  the 
elasticity  of  the  tissues  will  permit ;  not  the  slightest 


SEPARATION   OF   THE   TEETH.  151 

laceration  or  rupture  should  be  made ;  again,  great 
care  should  be  observed,  lest  strangulation  of  the 
vessels  that  enter  the  roots  be  effected ;  this  would  be 

Fig.  66. 


far  more  liable  to  occur  in  the  teeth  of  young  persons, 
or  before  maturity.  There  is  in  adults,  however,  a 
great  diversity  in  their  susceptibility  to  injurious 
influences. 

Many  operators  still  prefer  gradual  separation  by 
pressure.  In  order  to  secure  the  most  successful 
results  the  condition  of  the  parts  should  be  strictly 
observed.  The  gums,  periosteum,  etc.,  should  be  in 
a  healthy  condition,  for  much  injury  may  be  done 
by  attempting  to  separate  teeth  by  pressure  when  the 
contiguous  parts  are  in  an  irritable  state.  In  per- 
sons of  a  neuralgic  diathesis,  in  those  whose  vital 
energy  is  weak,  and  particularly  in  those  whose  con- 
stitutional tendency  is  inflammatory,  this  operation 
is  scarcely  admissible.  If,  in  such  cases,  it  is  at- 
tempted at  all,  it  should  be  proceeded  with  very  care- 
fully and  gradually,  and  should  be  preceded  by  con- 
stitutional treatment.  There  are  many  cases  in  which 


152  SEPARATION    OF   THE   TEETH. 

it  is  best  to  make  the  separation  partly  by  pressure, 
and  then  to  complete  it  by  dressing  off  the  thin  fria- 
ble cilucs  of  the  cavity  with  the  cutting  instrument 
or  file.  Whether  the  process  is  to  be  wholly  or  only 
partly  accomplished  by  pressure  should  be  determined 
beforehand. 

Various  materials  have  been  .employed  for  sepa- 
rating the  teeth  by  gradual  pressure,  the  chief  of 
which  are  cotton,  wood,  india-rubber  and  ligatures. 
The  condition  and  character  of  the  parts  to  be  ope- 
rated upon  will  usually  indicate  the  material  best 
adapted  in  any  given  instance.  In  a  good  constitu- 
tion, with  the  teeth  firmly  set  and  the  contiguous 
parts  healthy,  wood  or  india-rubber  may  be  applied, 
but  in  cases  of  an  opposite  character,  a  more  yield- 
ing and  tractable  material  is  indicated.  The  degree 
of  pressure  to  be  applied  and  continued  will  be  de- 
termined by  the  susceptibility  of  the  parts  to  irrita- 
tion. Soreness  usually  occurs  in  a  few  hours  after 
the  introduction  of  the  material.  The  pressure  should 
be  gradual  and  constant,  slight  at  first,  and  increased 
in  force  as  the  patient  will  bear,  the  increase  being 
made  every  day,  and  continued  till  ample  space  is 
obtained.  The  time  necessary  for  the  completion  of 
this  process  is  from  ten  to  twelve  days;  only  one 
separation  should  be  made  at  a  time.  The  teeth 
should  be  retained  apart  till  the  soreness  has  abated, 
before  the  operation.     If  not  thus  retained  too  long 


SEPARATION  OF  THE  TEETH.  153 

they  will  steadily  return  to  their  former  position.  It 
is  by  some  supposed  that  separation  by  pressure  is  ad- 
missible only  in  the  case  of  the  young,  or  those  under 
thirty  years  of  age.  It  is  true  that  they  are  the 
most  susceptible,  but  the  operation  is,  under  favora- 
ble circumstances,  proper  at  any  age. 


CHAPTER  VI. 


FILLING    TEETH. 


The  operation  of  filling  teeth  is  an  interesting  and 
important  one,  requiring  for  its  successful  accomplish- 
ment peculiar  talent  and  large  experience.  It  is  the 
only  means  as  yet  ascertained  of  completely  effect- 
ing the  object  for  which  it  is  employed,  namely,  ar- 
rest of  decay  and  preservation  of  the  organs.  Thera- 
peutic agents  avail  but  little  here,  so  low  is  the  or- 
ganization and  so  feeble  the  vital  power.  Nature,  so 
efficient  in  more  highly-organized  structures,  does 
comparatively  little  in  disease  of  the  teeth  toward 
arrest  or  restoration.  Yet,  on  the  other  hand,  these 
organs  are  less  liable  to  decomposition  by  the  action 
of  foreign  substances ;  indeed,  well-organized  enamel 
is  almost  invulnerable  to  any  agents  to  which  it  is 
ordinarily  exposed.  The  dentine,  however,  is  more 
easily  acted  upon,  and,  when  there  is  defect  in  the 
enamel,  is  very  liable  to  injury. 

Scarcely  an  individual  in  our  country  arrives  at 
mature  age  with  a  perfect  set  of  teeth ;  indeed,  nine- 
tenths  of  our  people  have  decayed  teeth  at  an  early 
period  of  life.  Hence,  for  beautifying,  preserving, 
and  supplying  these  organs,  art  is  in  constant  requi- 


EXAMINATION.  155 

sition,  and  in  these  respects  great  achievements  have 
been  made.  In  the  operation  of  filling  the  teeth,  es- 
pecially, the  achievements  are  conspicuous ;  and  here 
is  scope  for  the  highest  skill.  Every  successive  step 
in  the  process  of  filling  a  tooth  demands  a  complete 
and  conscientious  application  of  the  most  efficient 
and  best  adapted  modes  and  appliances  of  the  art.  In 
the  following  remarks  it  is  proposed  to  analyze  this 
whole  process,  examining,  in  their  order,  the  various 
steps  necessary  to  be  taken,  and  endeavoring  to  in- 
culcate the  true  methods  of  accomplishing  them. 

Examination. 

When  a  case  is  presented  there  should  first  be  a 
thorough  examination,  since  by  this  all  the  subse- 
quent work  will  be  modified.  For  this  purpose  the 
proper  exploring  instruments  should  be  at  hand, 
which  should  consist  of  a  sufficient  number  and  va- 
riety of  fine  sharp-pointed  instruments,  so  formed  and 
curved  as  to  be  readily  brought  into  contact  with 
every  point  of  surface  of  the  crown  of  every  tooth, 
and  indicate  any  defect  that  may  exist. 

The  accompanying  cut  represents  the  common  and 
perhaps  the  best  forms  of  this  class  of  instruments. 

In  addition  to  these,  mirrors,  reflectors,  and  mag- 
nifiers, when  properly  adjusted  and  skilfully  used, 
are  very  valuable. 


L56 


PILLING    'I  EETH. 


There  should  be  two  or  three  sizes  of  mirrors,  ad- 
justable to  any  angle  requisite  to  reach  every  point 
in  the  mouth  efficiently. 

Reflectors  are  desirable  for  throwing  light  upon  ob- 
scure or  dark  points. 

Fig.  67. 
IS  I  (  /       (T~      I 


Magnifiers  are  important  in  examination  of  the 
teeth,  to  bring  to  view  defective  points  that  would 
escape  detection  by  the  unassisted  eye.  Every  op- 
erator ought  to  have  at  hand  at  least  three  grades  of 


Fig.  68. 


these.  Mirrors  and  magnifiers  are  combined  to  some 
extent,  but  sufficient  amplification  and  definition  can- 
not always  be  obtained  in  this  way  for  all  cases.  The 
common  mouth-mirror  is  shown  by  Fig.  68. 


EXAMINATION. 


157 


Mirrors  and  reflectors  are  made  adjustable  upon 
the  finger  of  the  operator,  as  in 


Fig.  69. 


Reflectors  adjustable  on  the  rubber-dam  clamps 
serve  a  valuable  purpose,  and  should  always  be  at 
hand.     Shown  in 


jT\ 


Fig.  70. 


They  are  also  attached  to  the  rubber-dam  clamps, 
which  makes,  for  many  cases,  a  very  convenient  ar- 


rangement. 


Fig.  71  is  a  magnifier,  to  be  used  on  the  finger  of 
the  operator.  The  chief  use  of  the  magnifier,  how- 
ever, is  for  examination  rather  than  for  operating. 

The  points  to  be  noted  in  the  examination  arc  as 

follow-  : 


158  FILLING   TEETH. 

The  temperament ;  the  present  health  ;  the  consti- 
tutional tendencies  :  the  secretions, — the  saliva  and 
mucus ;  the  mucous  membrane  and  the  gums ;  the 
constitution  and  condition  of  the  teeth ;  the  num- 
ber of  them  remaining  in  the  mouth ;  the  number 
affected;  the  extent  and  nature  of  the  decay,  and 
the  character  of  the  agents  producing  it.  By  the 
examination  we  ascertain  how  to  proceed  in  the  op- 

Fig.  71. 


eration ;  if  much  or  but  little  labor  is  required ; 
whether  the  operation  will  be  a  simple  or  a  difficult 
one ;  and  if  difficult  what  circumstances  render  it 
so ;  and,  besides,  some  conclusion  is  arrived  at  in  re- 
gard to  the  precise  means  to  be  employed  for  obtain- 
ing the  desired  result,  as  well  as  the  permanency  of 

that  result. 

Opening. 

The  next  step  is  to  open  the  cavity  of  decay,  so 
that  it  may  be  approached   and  operated  upon  at  all 


OPENING.  159 

points.  The  particular  manner  of  performing  this  is 
determined  by  the  extent  of  the  decay,  and  its  posi- 
tion upon  the  tooth.  In  all  cases  the  opening  should 
be  such  as  to  give  free  access  to  all  parts  of  the 
cavity,  for  effectually  removing  the  decayed  portion, 
for  perfectly  forming  the  cavity,  and  for  introducing, 
thoroughly  consolidating  and  finishing  the  filling.  In 
central  crown  cavities  of  the  molars  and  bicuspids, 
the  projecting  or  pendent  portions  of  enamel  should 
be  cut  away.  There  are  cases,  however,  where  such 
portions  are  firm  and  not  liable  to  be  broken,  and 
where  they  can  be  well  sustained  by  filling  under,  in 
which  it  is  admissible  to  leave  some  projection.  This 
is  true  of  only  those  teeth  which  are  of  good,  firm 
texture.  There  are  two  objections  to  these  abrupt 
projections  of  enamel :  it  is  very  difficult  and  in 
many  cases  impossible,  to  fill  perfectly  beneath  such 
portions ;  and  again,  they  are  liable  to  be  broken 
down  during  mastication. 

For  opening  up  these  cavities,  in  many  cases  the 
bur  drill  alone  will  be  quite  sufficient ;  those  of  dif- 
ferent sizes  being  employed,  to  open  up  the  orifice 
lually,  so  that  too  much  violence  may  not  be  done 
to  the  teeth.  In  all  very  small  cavities,  the  bur  is 
all  that  is  required,  except  in  decayed  fissures,  and 
for  these  the  fissure  bur  is  almost  indispensable. 

In  cases  w)  ere  the  decay  is  more  extensive,  and 
the  cavity  larger,  the  chisel  or  heavy  cutting  instru- 


1G0 


FILLING    TEETH. 


ment,  in  connection  with  the  drill,  will  be  found  very 
useful.  Fig.  72  represents  valuable  forms  of  these 
instruments. 

Fig.  72. 


Fig.  8,  page  101,  represents  instruments  for  this 
purpose,  of  various  forms  and  sizes  ;  they  may  be 
used  either  with  hand  force  or  the  mallet.  In  cases 
where  much  cutting  is  required,  the  latter  method  is 
preferable,  being  more  rapid  in  execution,  and  less 
objectional  to  the  patient. 

The  fine  file  or  bur  should  always  follow  the  use 
of  the  chisels,  to  give  a  smooth  and  even  surface  to 
the  part  upon  which  the  cutting  has  been  made. 

Removal  of  Decay. 


After  the  cavity  is  opened,  the  next  step  in  order 
is  the  removal  of  the  decayed  dentine.  As  a  general 
rule,  this  should  be  entirely  removed.  There  is, 
however,  some  variety  of  opinion  upon  this  subject. 
This    difference    of    opinion    is   in    regard    to   cases 


REMOVAL    OF    DEC  AY.  161 

where  an  entire  or  a  partial  decomposition  of  the 
dentine  has  taken  place  quite  to  the  pulp,  where,  by 
its  removal,  the  pulp  would  be  exposed.  It  is  main- 
tained by  some  that  decayed  dentine  affords  a  better 
protection  to  the  pulp  than  any  artificial  covering ; 
and  hence  it  is  better  to  let  it  remain,  since  its  adap- 
tation is  more  complete  ;  and  it  is  not  in  every  sense 
a  foreign  substance. 

On  the  other  hand,  it  is  contended  that  the  de- 
cayed dentine,  being  in  an  abnormal  condition,  will 
irritate,  and  in  many  cases  ultimately  destroy,  the 
pulp.  And  again,  that  there  is  danger  of  making 
undue  pressure  upon  the  pulp,  in  filling  on  such 
softened  portion. 

In  many  cases  it  is  maintained  that  partially  de- 
composed dentine  will  become  dense  again,  if  pro- 
tected from  the  influence  of  foreign  agents  that  de- 
compose it.  This  sometimes  would  seem  to  be 
true.  For  in  some  cases  where  fillings  have  been 
introduced  into  cavities,  at  the  bottom  of  which  a 
portion  of  softened  dentine  covered  the  pulp,  on  re- 
moving them  in  from  one  to  five  years  afterward, 
all  parts  of  the  cavity  were  found  to  be  equally  and 
normally  dense.  This,  perhaps,  would  occur  only 
in  good  constitutions,  and  under  favorable  circum- 
stances; but  with  such  constitutions  and  circum- 
stances, where  the  softening  is  not  too  extensive, 
and   the   decomposition    but  partial,  it    may  be   per- 


1G2  FILLING    TEETH. 

m  it  ted  to  remain,  with  a  strong  liability  of  a  favor- 
able result.  This  would  certainly  be  better  than  to 
cut  it  all  away,  and  expose  and  perhaps  wound  the 
pulp,  and  then  endeavor  to  cover  it  with  some 
wholly  foreign  material  that  would  not  be  perfectly 
adapted  to  it,  that  would  press  a  little  too  hard  at 
one  point  and  not  touch  at  another,  and  that  would 
be  quite  as  liable  to  be  pressed  down  on  the  pulp  as 
the  softened  dentine. 

In  this  discussion  much  depends  upon  the  point, 
whether  partially  decomposed  dentine  can  retain  its 
vitality.  This  it  is  not  now  proposed  to  consider. 
There  are  some  particulars  in  regard  to  the  removal 
of  decay,  however,  about  which  there  is  no  diversity 
of  opinion  :  first,  that  all  decomposed  dentine  should 
be  removed  from  all  parts  of  the  cavity,  where  the 
pulp  would  not  be  exposed  or  injured  thereby;  and 
that  in  all  cases  it  should  be  entirely  removed  from 
the  lateral  walls  of  the  cavity,  and  especially  from 
the  vicinity  of  the  orifice.  Even  discolored  dentine 
should  be  removed  from  this  part,  unless  weakening 
of  the  borders  or  walls  would  thereby  be  occasioned. 

Dentine  often  becomes  changed  in  color  when 
there  is  no  apparent  decomposition  ;  such  portion  is 
usually,  though  not  always,  without  vitality.  It  is 
not  important  to  remove  such  changed  portion  ex- 
cept for  the  appearance  of  the  tooth;  it  will  produce 
no  change   upon  the   living  or  normal  part  beyond 


REMOVAL    OF    DECAY.  163 

it ;  and  it  is  better  material  to  be  in  contact  with 
the  living  part  than  any  metal  of  which  a  filling 
may  be  made. 

Decayed  dentine  is  readily  removed  with  the  ex- 
cavators. In  any  given  case,  such  instrument  should 
be  selected  as  would  be  best  adapted  for  the  pur- 
pose, as  well  in  regard  to  size  and  the  form  of  its 
edge,  as  to  the  curvature,  or  inclination  of  its  shaft. 
The  edge  of  the  instrument  should  come  upon  the 
walls  of  the  cavity  at  such  an  angle  as  to  accomplish 
the  work  most  efficiently.  It  should  be  very  sharp, 
and  pressed  firmly  to  the  bottom  of  the  decay  at 
one  side,  so  as  to  remove  the  principal  part  at  one 
cut.  So  far  as  possible,  the  direction  of  the  cutting 
should  always  be  from  the  nearest  point  of  pulp  ex- 
posure, toward  the  orifice  of  the  cavity.  With  the 
proper  instrument,  and  that  in  the  right  condition, 
all  the  decay  should  be  removed  from  any  cavity 
by  a  few  firm,  steady  strokes.  By  this  method  less 
pain  is  caused  the  patient,  and  the  work  of  the  oper- 
ator is  facilitated.  It  is  intolerable  to  think  of  being 
subjected  to  an  awkward,  clumsy  hand,  with  a  dull, 
ill-shaped  excavator,  scratching  upon  the  surface  of 
a  decayed  tooth,  for  a  length  of  time  apparently  to 
the  patient  intermimibU'. 


16  I  I  [LUNG    TKI.i  M. 

Forming  Cavities. 

The  next  step  in  the  operation  is  the  formation  of 
tlic  cavity.  By  this  the  cavity  is  so  formed  that  it 
will  well  receive  and  retain  the  filling  when  properly 
introduced.  In  very  few  cases  is  the  cavity  of 
proper  form  when  the  decay  is  removed  ;  hut  in  al- 
most every  instance  more  or  less  of  the  solid  dentine 
must  be  removed  to  secure  a  proper  form  to  the  cav- 
ity. Much  time,  patience  and  labor  are  required  of 
the  operator  for  the  proper  accomplishment  of  this 
part  of  the  work,  and  much  endurance  on  the  part 
of  the  patient.  In  this  part  of  the  work  several 
particulars  require  consideration.  The  great  object, 
however,  is  to  give  to  the  cavity  such  a  form  as  will 
secure  the  most  perfect  adaptation  of  the  filling  to 
every  point,  and  its  permanent  retention  in  place. 
The  cutting  for  the  formation  of  the  cavity  should 
be  accomplished  with  the  least  possible  loss  of  healthy 
dentine;  this  is  a  point  upon  which  good  judgment 
should  be  exercised.  The  strength  of  the  walls  of 
the  cavity,  and  the  ability  of  the  parts  to  withstand 
the  pressure,  both  in  the  introduction  and  consolida- 
tion of  the  filling  and  in  the  act  of  mastication, 
should  be  well  noted.  It  may  be  regarded  as  a  rule 
from  which  there  should  scarcely  ever  be  a  depar- 
ture, that  the  enamel  should  never  be  encroached 
upon,  through  the   dentine,   in  excavating    to    give 


FORMING    CAVITIES.  1G5 

form  to  a  cavity.  When  there  is  but  a  lining  of  den- 
tine at  any  given  point  on  enamel,  after  the  decay 
is  removed,  it  should  remain  for  the  preservation 
of  the  enamel  ;  it  should  not  be  cut  through  either 
by  pits  or  by  grooves,  much  less  should  any  consid- 
erable portion  be  removed. 

There  are  cases  occasionally  in  which  the  dentine 
is  wholly  decayed,  and  its  removal  lays  bare  the 
enamel ;  when  such  a  case  occurs,  the  enamel  should 
be  retained  in  as  perfect  a  condition  as  possible,  and 
no  attempt  made  to  form  pits  or  grooves  in  it.  The 
reason  for  this  is  found  in  the  friability  of  the 
enamel. 

It  may  be  regarded  as  an  axiom,  that  where  it  is 
necessary  to  cut  the  healthy  dentine  to  give  proper 
form  to  the  cavity,  it  should  be  done  at  that  part  of 
the  cavity  where  the  tooth  will  suffer  least  from  the 
loss.  The  precise  point  and  amount  of  cutting  will 
be  determined  by  the  form  and  size  of  the  cavity, 
and  the  amount  of  solid  dentine  remaining  after  the 
decay  is  removed. 

In  small  cavities,  where  there  is  sufficient  material 
to  work  upon,  the  object  is  to  give  the  cavity  a  reg- 
ular form,  and  make  the  retaining-points  where  it  is 
most  convenient  and  efficient. 

In  large  cavities,  where  one  side  of  the  tooth  is 
w.-ak,  places  must  he  selected  for  making  the  re- 
taining-points that  will  least  affect  the  weak  point 


166  FILLING    TEETH. 

Frequently,  in  proximate  decay  of  the  anterior  teeth, 
the  labial  and  palatal  walls  are  friable,  and  would 
be  easily  broken;  much  cutting  upon  such  walls 
would  not  be  admissible.  Again,  the  decay  often 
extends  towards  the  point  of  the  tooth,  down  to  the 
union  of  the  labial  and  palatal  plates  of  enamel;  in 
cases  of  this  kind,  all  that  can  be  done  at  this  point 
is  to  remove  the  decay  ;  and  fracture  will  sometimes 
occur  even  in  accomplishing  this. 

In  some  instances,  as  in  the  crown  cavities  of  the 
molars,  the  cavity  will  be  nearly  or  quite  of  proper 
form  when  it  is  perfectly  open,  and  the  decay  all  re- 
moved. This  is  the  case  when  the  decay  is  confined 
to  a  simple  perforation  of  the  dentine,  without  any 
considerable  lateral  extensions.  In  proximate  cav- 
ities there  is  always  more  or  less  excavation  of  the 
solid  dentine  required,  to  give  the  cavity  proper  form. 

There  is  no  definite  rule  for  the  formation  of  cav- 
ities, that  will  be  applicable  in  all  cases.  The  form 
will  be  modified  by  the  tooth,  the  position  of  the 
decay  upon  it,  the  extent  and  ramifications  of  the 
decay,  and  the  manner  in  which  it  is  to  be  filled.  It 
is  given,  by  some,  as  a  rule,  that  the  depth  of  a  cavity 
should  be  equal  to  its  least  diameter.  This  is  a  direc- 
tion, however,  of  no  general  application,  for  many 
cavities  will  be  much  deeper  than  the  greatest  diam- 
eter, as  in  crown  cavities  of  the  molars ;  and  the  re- 
verse will  often  occur,  as  in  labial  cavities  of  the  supe- 


FORMING   CAVITIES.  167 

rior  incisors,  and  in  proximate  cavities  of  the  molars. 
in  which  it  would  be  impossible  to  make  anything 
like  an  approach  to  this  rule,  without  exposing  the 
pulp,  and  even  cutting  through  its  chamber. 

A  general  direction,  and  one  that  we  think  good, 
and  applicable  in  many  cases,  especially  in  crown 
cavities  of  the  molars,  and  in  almost  any  of  the 
deep  perforations  by  decay,  is  to  make  the  walls  of 
the  cavity  as  nearly  as  practicable  parallel  with  one 
another.  This  rule  is  applicable  in  almost  all  small 
cavities. 

In  medium  or  large-sized  cavities,  it  is  admissible 
to  leave  them  slightly  larger  at  the  bottom,  than  at 
the  orifice,  if  circumstances  require;  a  large  cavity 
of  this  form  can  be  perfectly  filled,  when  a  small 
one  could  not,  from  the  fact  that  in  the  former  there 
is  more  room  to  operate  in  introducing,  adapting  and 
consolidating  the  filling. 

Cavities  that  are  larger  within  than  at  the  orifice, 
should  have  their  walls  perfectly  plain,  smooth  sur- 
faces, free  from  transverse  grooves  or  depression- 
that  the  gold  may  be  accurately  adapted  to  them. 

It  is  sometimes  necessary  to  leave  a  cavity  slightly 
larger  at  the  orifice  than  at  the  bottom.  This  may 
be  done  by  a  diverging  inclination  of  the  wall  of  one 
or  more  -ides  of  the  cavity.  When  there  is  an  in- 
ward inclination  of  the  wall  at  one  side  of  the  cavity, 
the  genera]  form  may  be  such  as  to  retain  a  filling 


lUX  PILLING    TEETH. 

perfectly,  for  there  may  be  two  opposite  sides  parallel, 
or  even  divergent;  in  that  case,  the  axis  of  the  cav- 
ity will  not  be  in  the  direction  of  the  centre  of  the 
crown. 

Two  opposite  sides  may  converge  and  the  others 
diverge,  and  a  filling  be  retained  firmly.  When  two 
contiguous  sides  have  the  same  converging  inclina- 
tion, making  the  orifice  larger  than  the  interior,  if 
the  walls  are  smooth,  plain  surfaces,  a  filling  will  not 
be  retained;  but  retaining-points  may  be  made  by 
forming  transverse  grooves  or  pits  upon  them,  and 
by  this  means  the  filling  be  firmly  retained.  As  a 
general  rule,  it  will  be  necessary,  when  the  orifice  is 
larger  than  the  cavity  within,  to  make  grooves  or 
pits  on  the  wall.  For  this  purpose  the  diamond- 
point  excavator  is  invaluable. 

If  the  cavity  is  large,  and  the  walls  near  the  orifice 
thin,  and  liable  to  be  broken,  the  situation  of  the 
grooves  or  under-cutting  should  be  farther  within  the 
cavity  than  if  the  walls  are  firm  out  to  the  edge. 
Sometimes  it  is  best  to  make  little  pits  at  the  bottom 
of  such  cavities  for  retaining-points.  In  cases  where 
it  is  necessary  to  make  an  under-cutting,  one  or  two 
little  transverse  grooves  upon  one  side  will  be  suffi- 
cient, and  in  no  case  on  more  than  two  sides,  leaving 
the  others  perfectly  plain  surfaces. 

In  the  formation  of  retaining-points  in  difficult 
cavities,  there  is  considerable  diversity  of  practice  : 


FORMING   CAVITIES.  .  169 

under-cutting  and  grooving  have  been  very  com- 
monly employed.  Another  method  in  common  use 
is  that  of  drilling  little  holes  or  pits  into  the  dentine 
at  the  most  favorable  points,  these  taking  different 
directions.  This  kind  of  retaining-points  is  much 
better  calculated  to  answer  the  purpose,  in  filling 
with  crystal  gold,  or  cohesive  foil,  than  with  the  or- 
dinary non-cohesive  foil  after  the  old  methods.  When 
these  perforations  are  made  at  different  inclinations, 
and  then  perfectly  filled  with  cohesive  gold  of  any 
kind,  the  filling  will  certainly  be  retained  in  place. 
For  making  these  perforations,  a  small  square-edged 
drill  is  the  proper  instrument. 

Such  retaining-points  are  seldom  or  never  required 
in  crown  cavities  of  the  molars;  but  in  proximate 
cavities  they  are  frequently  employed  with  great  ad- 
vantage. In  forming  them  care  should  be  exercised, 
lest  the  pulp-chamber  is  encroached  upon  by  the  in- 
strument. In  almost  all  cases,  the  proper  point  for 
forming  them  is  in  the  cervical  wall  of  the  cavity. 

Some  operators  discard  any  definite  retaining-points, 
grooves  or  angles,  but  aim,  instead,  to  give  a  general 
retaining  form  to  that  part  of  the  cavity  in  which 
the  filling  is  to  be  commenced,  and  upon  which  re- 
liance is  to  be  placed  for  its  retention.  The  advan- 
tage of  definite  retaining-points  is  twofold;  first,  to 
facilitate  the  introduction  of  the  first  part  of  the  fill- 


170  PILLING    TEETH. 

ing  ;  and  second,  its  more  certain  retention  after  if  is 
in  position. 

Another  particular  to  which  attention  should  be 
given  is  the  border  of  the  orifice.  It  should  always 
be  an  object  to  secure  an  even,  smooth  and  strong  bor- 
der to  the  orifice  of  the  cavity.  It  is  impossible  to 
make  a  good  finish  with  a  rough,  uneven  border; 
the  filling  is  also  more  exposed  to  injury  by  mastica- 
tion. The  integrity  of  a  smooth,  plain  surface  is 
retained  under  influences  that  would  break  up  and 
destroy  an  uneven  one.  Some  operators  polish  the 
borders  of  all  cavities,  before  filling,  as  perfectly  as 
possible,  and  regard  no  reasonable  amount  of  labor 
in  this  direction  as  lost.  This  polishing  certainly 
adds  to  the  security  of  an  operation.  It  is  also  very 
desirable  to  have  a  firm  margin  ;  to  obtain  this,  it  is 
often  necessary  to  cut  away  more  than  would  other- 
wise be  desirable.  A  smooth,  firm  border  should  not 
be  sacrificed  for  the  form,  and  especially  in  the  pos- 
terior teeth.  It  is  very  objectionable  to  some  persons 
to  have  the  perfect  form  of  the  front  teeth  marred  or 
changed  ;.  but  it  should  be  remembered  that  even  a 
front  tooth  one  third  cut  away,  and  so  filled  as  to  be 
permanently  preserved,  is  far  more  valuable  than  an 
artificial  one. 

Another  particular  that  should  always  be  observed, 
is  the  removal  of  all  acute  angles,  and  especially 
when  they  are  in  the  vicinity  of  the  orifice  of  the 


FOKMIXG    CAVITIES.  171 

cavity.  These  are  seldom  or  never  found  in  proxi- 
mate cavities  of  the  molars  and  bicuspids  ;  occasion- 
ally they  are  found  in  proximate  cavities  of  the  cus- 
pids, and  frequently  in  proximate  cavities  of  the  in- 
cisors, particularly  at  that  part  of  the  cavity  next  to 
the  cutting  edge  of  the  tooth.  Such  angles  are  very 
often  found  also  in  crown  cavities  of  the  molars  and 
bicuspids,  where  there  is  an  extension  of  the  decay 
along  one  or  more  of  the  fissures  of  the  crown. 

It  is  difficult — almost  impossible — to  fill  perfectly 
a  sharp  angle,  and  hence  the  necessity  of  obliterating 
such  when  it  occurs.  This  may  be  done  either  with 
a  small  delicate  cutting  instrument  or  with  a  small 
bur  drill.  It  is  an  operation  requiring  great  care 
and  delicate  manipulation,  at  least  so  far  as  the  an- 
terior teeth  are  concerned.  When  a  sharp  angle 
occurs  in  the  proximate  cavities  of  the  front  teeth, 
it  is  usually  near  the  cutting  edge  of  the  tooth,  just 
at  the  union  of  the  labial  and  palatal  plates  of  en- 
amel. A  small  chisel-shaped  instrument  is  very 
I  lor  cutting  out  such  angles  ;  indeed,  in  fissures 
of  crown  cavities  of  molars,  where  the  decay  extends 
backward,  the  straight  chisel-shaped  instrument  is 
just  adapted  to  this  purpose;  but  where  there  is  an 
anterior  extension,  the  instrument  should  be  curved 
to  almost  a  right  angle,  and  forced  down  by  pressure 
of  the  thumb  of  the  left  hand.  The  small  burs  and 
fissure  drills,  represented  by  Figs.  20  and  22,  used 


172  PILLING   TEETH. 

with  the  dental  engine,  will  meet  the  requirements 

in  such  cases  with  great  facility.  Some  good  opera- 
tors recommend  a  slight  reaming  at  the  orifice  of  all 
cavities,  where  it  can  he  accomplished.  The  object 
of  this  is  twofold :  to  remove  the  sharp  angle  at  the 
orifice  of  the  cavity,  as  it  is  liable  to  be  fractured  or 
roughened  in  putting  in  the  filling;  and  to  give  a 
better  margin  to  the  filling.  In  making  this  bevel, 
the  bur,  if  one  be  used,  should  be  but  little  larger  than 
the  orifice  of  the  cavity.  The  cutting  should  be  but 
slight — just  sufficient  to  remove  the  sharp  corners  ; 
much  cutting  here  w^ould  give  too  thin  and  yielding 
an  edge  to  the  filling. 

Exclusion  of  Moisture. 

The  complete  and  certain  exclusion  of  saliva,  and 
all  moisture  from  a  tooth  that  is  to  be  filled,  has 
ever  been  a  great  desideratum  ;  and  till  within  a 
comparatively  recent  period,  was  attained  with  diffi- 
culty. A  great  many  appliances  and  methods  have 
been  employed  for  the  accomplishment  of  this  object. 
The  usual  method  was  to  pack  about  and  around  the 
tooth  upon  which  an  operation  was  to  be  performed 
napkins,  bibulous  paper,  spunk,  etc.,  retained  in 
place  by  holders.  These,  in  most  cases,  were  effect- 
ual but  for  a  short  time,  and  when  the  flow  of  saliva 
was  abundant,  constant  vigilance  and  effort  were  nee- 


EXCLUSION   OF   MOISTURE.  173 

essary  to  secure  the  proper  exclusion  of  moisture. 
Quite  a  variety  of  instruments  and  appliances  have 
been  employed  for  holding  in  place  these  various 
paddings.  Some  of  them  were  to  be  held  by  the 
patient,  others  were  so  formed  as  to  clamp  the  rolls 
or  pads  firmly  in  place. 

None  of  these  appliances  had  reference  to  check- 
ing the  flow  of  saliva  by  compression  upon  the 
mouths  of  the  ducts ;  this,  however,  in  due  time 
was  introduced.  Various  appliances  and  adjustments 
were  made  with  this  object  in  view.  Pads  of  cloth, 
bibulous  paper,  spunk,  and  disks  of  pipe-clay,  were 
the  principal  things  used  for  this  purpose ;  they  were 
placed  and  held  firmly  on  the  mouths  of  the  ducts 
by  clamps,  springs,  etc.  A  good  degree  of  success 
was  in  this  way  attained  in  some  cases,  in  others  it 
is  impossible  to  close  all  the  ducts  ;*  and  in  almost 
every  instance  these  things  stimulate  an  excessive 
flow  of  mucus.  Filling  the  mouth  in  the  manner 
just  described  was  always  objectionable  to  the  patient, 
and  in  many  instances  could  not  be  tolerated. 

In  addition  to  all  these  things,  various  pumps  were 
devised  for  removing  the  saliva  from  the  mouth  as  it 
accumulated,  all  of  which  were  more  or  less  objec- 
tionable. 

All  these  modes  and  appliances  have  been  super- 
seded by  the  introduction  and  use  of  the  rubber  dam 
and  saliva  extractor.      For  tin;  former  of  these  the 


174 


FILLING    TEETH. 


profession  is  indebted  to  Dr.  S.  C.  Barnum,  and  for 
the  latter  to  Dr.  J.  E.  Fisk. 

The  rubber  dam  is,  by  all  those  who  understand 
its  use,  justly  regarded  as  an  invaluable  boon.  It 
can  in  an 3'  and  all  cases  be  applied  so  as  to  abso- 
lutely exclude  moisture  from  a  tooth  or  teeth  while 
being  operated  upon.  It  does  not,  however,  prevent 
the  free  flow  of  saliva  into  the  mouth,  and  in  many 
cases  this  occurs  to  a  very  objectionable  extent,  and 
either  the  patient  must  swallow  it, — and  with  the 
rubber  dam  in  place  very  few  can  do  this, — or  it  must 
overflow  from  the  mouth,  which  is  very  unsightly, 
inconvenient,  and  annoying,  or  it  must  be  drawn 
from  the  mouth. 

About  ten  years  ago  Dr.  Fisk  made  available 
the   principle   of  the    Gifford    injector,  devising  the 

Fig.  73. 


saliva  extractor,  a  very  valuable  appliance  indeed  ; 
one  that  with  a  constant  stream  of  water  performs 
its  work  perfectly.  The  above  cut  gives  a  sectional 
view  of  it. 

An  instrument  constructed  by  Dr.  George  B.  Snow 


EXCLUSION   OF    MOISTURE. 


175 


for  the  same  purpose  gives  promise  of  great  useful- 
ness. In  principle  it  is  a  compromise  between  the 
Gifford    injector   and   the   siphon.       It  requires   for 


Fig.  74. 


Fig.  75. 


operation  but  a  small  amount  of  water — about  one 
quart  per  hour.       The   water  requisite  for  its  work- 


176  FILLING    TKKI  II. 

ing  is  contained  in  a  reservoir  holding  about  two 
quarts. 

This  instrument  is  very  efficient  and  uniform  in 
its  operation.     It  is  shown  in  Fig.  74. 

The  most  efficient  appliance  of  this  kind  is  now 
attached  to  the  fountain  spittoon,  which  in  its  oper- 
ation leaves  nothing  further  to  be  desired.  See  ac- 
companying illustration  (Fig.  75). 

With  either  of  these  appliances,  the  mouth  can 
be  kept  for  any  length  of  time  entirely  free  from  an 
excess  of  saliva. 

The  rapid,  easy  and  efficient  application  of  the 
rubber  dam  is  not  attained  without  some  manipula- 
tive skill  and  experience.  It  is  prepared  for  dental 
purposes  of  three  or  four  grades,  in  respect  to  thick- 
ness ;  the  thinnest  is  about  as  thick  as  a  sheet  of 
common  commercial  note  paper;  the  other  extreme 
would  be  represented  by  about  six-ply  of  the  same 
paper. 

This  web  should  be  made  of  rubber  of  the  finest 
quality,  and  free  from  all  foreign  substances.  Hav- 
ing selected  that  of  the  desired  thickness,  cut  a  piece 
six  inches  wide  and  from  six  to  ten  inches  long;  select 
the  proper  place  or  places  for  perforating  it  for  the 
teeth ;  for  this,  three  sizes  of  punches  will  be  re- 
quired :  one  about  a  line  and  a  half  in  diameter,  for 
the  molars ;  one  about  a  line  in  diameter,  for  the 
superior  incisors  and  bicuspids,  and  one  half  a  line, 


EXCLUSION    OF    MOISTURE. 


177 


for    the  inferior   incisors,   and  sometimes   for   small 
superior  incisors. 

These  punches  are  shown  in  Fig.  76.  A  prefera- 
ble form  of  punch  is  presented  in  Ainsworth's  rub- 
ber dam  punch,  shown  in  Fig.  77.      It  consists  of  a 

Fig.  76. 


general  forceps-form,  having  attached  to  one  of  the 
jaws  a  solid  cone  punch,  which  cuts  the  rubber 
against  a  perforated  die,  which  is  placed  upon  the 
other  jaw ;  this  die  revolves  so  as  to  bring  each  hole 
with  a  stop  under  the  cone;  there  are  four  holes  of 


i-' 


178 


EXCLUSION    OF   MOISTURE.  179 

graded  sizes.  This  is  by  far  the  most  efficient  in- 
strument yet  devised  for  this  purpose.  The  distance 
between  the  holes  in  the  cloth  should  be  from  one 
line  to  two  lines  and  a  half,  governed  by  the  dis- 
tance between  the  necks  of  the  teeth  to  which  it  is 
to  be  applied. 

The  following  accessories  should  be  at  hand  and 
ready  for  use  before  beginning  its  application  to  the 
teeth  : 

Silk  Thread.— That  known  as  surgeons'  or  sad- 
dlers' silk  is  well  adapted  to  the  purpose.  There 
should  be  at  least  two  sizes  of  this. 

For  some  cases  the  floss  silk  is  better  adapted 
than  the  thread.     These  should  always  be  at  hand. 

The  clumps  for  rubber  dam  are  indispensable ;  they 
are  of  various  forms  and  sizes,  and  are  now  made 
adapted  to  all  teeth  ;  and  in  addition  there  is  quite  a 
number  of  extras  for  special  cases. 

The  following  cut  represents  the  set  for  the  supe- 
rior teeth  of  the  right  side,  each  of  which  has  been 
formed  and  adapted  to  the  respective  tooth  upon 
which  it  is  to  be  used. 

There  are  in  the  full  set  thirty-two,  and  a  few  for 
special  cases,  thus  making  by  far  the  most  complete 
and  efficient  series  of  these  clamps  ever  devised. 

The  profession  is  largely  indebted  to  Dr.  Delos 
Palmer  for  the  most  efficient  clamps  that  have  been 


ISO 


FILLING   TEETH. 


in  use  for  several  years,  and  wholly  indebted  to  him 
for  the  very  perfect  set  represented  below. 

The  clamps  are  usually  placed  on  the  teeth,  after 
the  rubber-cloth  is  drawn  over  them,  for  the  pur- 
pose of  retaining  it  in  a  proper  position.  Often- 
times, however,  the  rubber  may  be  drawn  over  the 


r.  s.,i. 


R.  S.,  2. 


!:.  3.,  i. 


R.  8.,  5. 


R.  8.,  fi. 


R.  S.,7. 


R.  8.,  8. 


clamp,  and  then  both  together  be  placed  upon  the 
tooth.  This  method  is  usually  employed  only  when 
one  tooth  is  to  be  protected. 

For  this  adjustment  upon  the  teeth,  clamp-forceps 
are  in  requisition.  They  are  so  formed  as  to  pass 
into  the  curve  of  the  clamp,  and  by  pressure  upon 
the  handles,  open  it  sufficiently  to  pass  on  to  the 
crown  of  the  tooth,  the  rubber  then  being  drawn 
under  the  jaws  of  the  clamp. 

Fig.  79  represents  the  clamp-forceps  in  common 
use. 


EXCLUSION    OF    MOrSTURE, 

Fir;.  79. 


181 


182 


FILLING   TEETH. 


The  elastic  strap,  with  clamps  or  catches  attached, 
is  necessary  for  holding  away  the  upper  free  portions 
of  the  rubber  cloth  (Fig.  80). 


Fig.  80. 


The  weights,  also,  for  holding  out  of  the  way  the 
lower  free  portions  of  the  rubber  cloth,  are  used  by 
many.  These  are  shown  in  Fig.  81.  The  work  of 
the  ordinary  rubber  dam  clasps  and  weights  is  much 
better  done  by  the  little  appliance  found  in  notion  or 
furnishing  stores,  called  the  sleeve  elastic  ;  it  consists 
of  an  elastic  band  three  or  four  inches  long,  with  a 


EXCLUSION    OF    MOISTURE. 


183 


spring  clasp  upon  each  end,  the  beaks  of  which  are 
serrated,  so  that  they  retain  a  firm  hold  of  anything 
to  which  they  are  attached.       They  can  be  obtained 


Fig.  81. 


at  any  gentlemen's  furnishing  store  for  a  few  cents 
per  pair ;  they  are  easy  of  application  and  really 
supersede  any  other  appliance  for  holding  the  rub- 
ber dam.     It  is  shown  in  Fig.  82. 


Fio.  B2. 


Various  sizes  :md  forms  of  wedges  will  be  required; 
these  should  be  prepared  beforehand,  or  they  may 
be  made  al  the  time  they  are  to  be  used;  their  adap- 
tation to  the  peculiarities  of  the  case  in  hand  rather 

favors  this  com 


L8  I  FILLING    TEETH. 

Jarvis  separators  should  always  be  ai  hand,  to 
press  apart  any  teeth  thai  may  stand  so  firmly  in 
contact  as  to  prevent  the  rubber  from  passing  readily 
bet  \\  een  them. 

Fig.  -■".. 


Having  now  come  to  that  point  when  the  rubber 
dam  is  to  be  applied,  various  questions  and  consider- 
ations occur  : 

First. — Upon  how  many  teeth  shall  the  dam  be 
placed  ? 

The  character  of  the  operation  will  determine  this. 
For  a  simple  crown  cavity  of  either  a  superior  or 
inferior  molar,  if  the  opening  of  the  mouth  is  capa- 
cious, the  embrace  of  one  tooth  may  be,  and  often  is, 
sufficient.  If,  however,  the  mouth  he  small,  or  the 
tooth  unfavorably  located,  two  or  even  three  teeth 
should  be  included,  even  for  such  a  cavity  as  just 
indicated.  For  filling  proximate  cavities,  two  or  more 
teeth  should  always  be  included,  and  more  frequently 
three  or  four.  The  difficulties  liable  to  occur  from 
the  embrace  of  an  insufficient  number  are,  encroach- 
ment of  the  cloth  upon  the  locality  of  the  operation 
(the  size  of  the  mouth  and  its  behavior  will  modify 


EXCLUSION    OF    MOISTURE.  185 

this,  however),  and  the  liability  of  leakage  about  the 
last  teeth  included  in  the  embrace. 

A  sufficient  number  should  in  every  case  be  in- 
cluded to  meet  the  requirements,  and  no  more.  The 
practice  of  placing  the  rubber  upon  eight  or  ten 
teeth,  when  two  or  three  at  most  would  be  sufficient 
should  not  be  encouraged  or  allowed.  It  is  a  waste 
of  time  for  the  operator  and  an  unnecessary  annoy- 
ance to  the  patient. 

In  the  application  of  the  dam,  if  it  is  to  be  put 
upon  two  or  more  teeth,  it  should  first  be  placed 
upon  that  tooth  which  is  most  accessible,  then  upon 
the  next  one,  and  so  on  till  all  the  selected  ones  are 
included.  As  the  rubber  is  drawn  over  the  crown  of 
each  tooth,  the  thread  or  floss  should  be  passed  be- 
tween it  and  its  neighbor,  carrying  down  to  the 
margin  of  the  gum  the  rubber  that  is  between  the 
holes ;  this  process  should  follow  the  application  of 
the  rubber  to  each  tooth. 

The  rubber  will  often  pass  with  difficulty  between 
the  teeth,  either  because  of  firm  contact  or  because 
of  roughness  upon  the  proximate  surfaces  of  the 
teeth,  the  latter  sometimes  causing  tearing  of  the 
rubber.  To  meet  the  former  difficulty,  the  sepa- 
rators (Fig.  83)  may  be  used,  and  sufficient  space 
readily  obtained  to  afford  an  easy  passage  between 
the  teeth,  and  a  very  thin  saw  for  the  removal  of  the 
roughness;   this,    however,  should   never   be  applied 


186  filling  'i  r.r.ni. 

to  tlic  perfect  surfaces  of  the  teeth  ;  and  in   respect 
to  the  rubber,  moistening  it  with   ;i   solution  of  fine 
soap,  of  proper  consistence,  will  greatly  facilitate  its 
-  ige  between  the  teeth. 

The  rubber  cloth  now  being  upon  the  teeth,  the 
elastic  band  with  its  clasps  should  be  attached  to  the 
upper  free  border  al  each  side,  and  drawn  round  the 
head  sufficiently  to  keep  them  out  of  the  way;  then 
the  thread,  in  connection  with  a  small,  properly- 
formed  instrument,  will  be  applied  for  turning  the 
border  of  the  rubber  about  each  tooth  down  beneath 
the  margin  of  the  num.  the  thread  accomplishing  this 
between  the  teeth  and  the  instrument,  at  the  labial 
and  lingual  surfaces.  This  is  a  part  of  the  work 
that  should  be  carefully  and  thoroughly  performed  ; 
the  absolute  exclusion  of  the  moisture  depends  much 
upon  this.  Ligatures  are  sometimes  tied  tightly  round 
the  necks  of  the  teeth,  for  the  purpose  of  holding 
the  rubber  in  place  about  them;  this,  however,  is  sel- 
dom required. 

After  this,  the  wedges,  if  required,  should  lie  in- 
troduced. The  objects  to  be  gained  by  these  are, — 
increase  of  space  between  the  teeth ;  to  retain  the 
septum  of  the  rubber  against  the  gum,  and  press  the 
gum  up  somewhat,  and  thus  effect  greater  security 
against  the  encroachments  of  moisture;  and  to  pro- 
tect the  gum  from  injury  by  the  instruments  which 
are  to  be  subsequently  used. 


EXCLUSION    OF    MOISTURE.  187 

The  elastic  clasps  should  now  be  .applied  to  the 
borders  of  the  rubber,  in  such  a  manner  as  to  keep 
them  in  a  desirable  position.  With  the  rubber  dam 
thus  adjusted,  and  the  "saliva  extractor"  in  proper 
order  and  in  place,  there  will  be  no  difficulty  with 
moisture  or  an  overflow  of  saliva  in  any  case,  and 
the  succeeding  steps  may  be  conducted  with  the  ut- 
most security,  so  far  as  moisture  is  concerned. 

Some  operators  apply  the  rubber  dam  in  almost 
every  instance  prior  to  the  removal  of  decay  and  the 
formation  of  the  cavity  for  filling ;  and  doubtless  in 
many  cases  it  is  the  preferable  course,  the  only  ob- 
jection to  it  being  the  prolonged  inconvenience  to 
the  patient ;  but  for  this  there  is  perhaps  full  com- 
pensation, in  the  greater  facility  afforded  in  the  re- 
moval of  decay  from  and  the  excavation  of  the  cav- 
ity ;  with  the  entire  absence  of  saliva  and  moisture, 
the  work  can  be  effected  with  greater  rapidity  and 
precision ;  improper  cutting  is  less  liable  to  occur, 
and  less  pain  is  given  to  the  patient. 

After  the  rubber  dam  is  properly  adjusted,  it  is  an 
easy  matter,  with  bibulous  paper  or  some  similar  sub- 
stance, to  render  the  tooth  and  the  part  to  be  operated 
upon  thoroughly  dry.  Every  particle  of  debris,  cut- 
tings of  dentine,  etc.,  should  be  removed  from  the 
cavity  before  it  is  filled.  This  removal  may  be 
effected  by  the  small  scoop-shaped  instruments,  of 
which  there   .should   be  three  or  four  sizes.     In  con- 


188 


BILLING    TEETH. 


nection   with   these,  the  "  ehip  blower  "  or  warm  air 

blowpipe,  illustrated  in  Fig.  84,  may  be  advantage- 
ously used. 

This  instrument  consists  of  a  small  blowpipe,  with 
a  cylinder  an  inch  long  and  half  an  inch  in  diameter; 
this  is  placed  down  within  two  inches  of  the  point 
of  the  instrument.  This  cylinder  is  either  made  of 
very  heavy  metal-,  or  filled  with  wire  or  something 
that  will  retain  heat ;  on  the  other  end  is  attached  a 

Fig.  84. 


stiff  india-rubber  ball,  with  an  eyelet  opening,  one- 
fourth  inch  in  diameter.  By  placing  the  thumb  upon 
this  opening  and  making  compression,  a  jet  of  air  is 
forced  through  the  point  of  the  pipe,  and  the  cylinder 
being  previously  heated,  the  temperature  of  the  jet 
will  be  governed  by  that  of  the  cylinder,  and  the 
velocity  with  which  it  is  forced  through  the  instru- 
ment. This  jet  thrown  in  a  cavity  that  has  been 
made  as  dry  as  possible  by  wiping,  soon  makes  a 
very  perceptible  change,  the  walls  becoming  whiter 
than  before.  This  we  consider  the  most  desirable 
condition  in  respect  to  dryness  that  can  be  obtained. 


INTRODUCTION    OF    THE    FILLING.  189 

Introducing  the  Filling. 

Having  in  all  these  steps  for  the  preparation  of 
the  cavity  made  thorough  work,  the  next  thing  to  be 
accomplished  is  the  introduction  and  consolidation 
of  the  filling.  The  manner  of  performing  this  part 
of  the  work  will  be  governed  by  the  kind  of  material 
employed,  and  also,  somewhat,  by  the  form  of  the 
particular  material,  as  well  as  the  method  adopted. 
Some  materials,  as  gold,  for  instance,  may  be  used  in 
six  or  eight  different  forms,  each  involving  a  prin- 
ciple peculiar  to  itself;  and  each  of  these  forms  is 
susceptible  of  being  used  in  different  ways.  It  is 
proposed  to  describe,  as  clearly  and  concisely  as 
possible,  the  various  methods  of  filling  that  have 
been  found  efficient.  This  is  the  more  important, 
since  different  operators  differ  in  their  election  of 
methods  ;  some  preferring  one,  others  another, — the 
result  of  mere  choice,  habit,  or  some  peculiar  fitness. 

The  first  method  for  consideration  is  that  of  filling 
with  ordinary  non-cohesive  gold  foil.  The  principles 
applicable  to  the  use  of  this  kind  of  foil  also  obtain 
in  the  use  of  foils  of  other  metals.  Gold  is  used  far 
more  than  anything  else.  The  common,  and,  indeed, 
tin-  almost  universal  method  of  using  foil,  in  the  early 
periods  of  the  profession,  was  in  the  form  of  a  roll, 
or  rope,  as  it  is  sometimes  called.  By  this  method 
the  foil   is  cut  into  strips  from  one-third  of  an  inch 


190  FILLING    TEETH. 

to  two  inches  wide,  the  width  being  governed  some- 
what by  the  size  of  the  cavity  to  be  filled.  This 
strip  is  then  rolled  lengthwise,  forming  a  loose  roll. 
The  compactness  of  the  roll  should  depend  upon  the 
thickness  of  the  foil,  and  the  size  of  the  points  with 
which  it  is  to  be  condensed  ;  the  smaller  the  points, 
the  more  compact  the  roll  may  be. 

It  may  be  introduced  either  with  the  condensing 
instrument  or  with  the  plugging  pliers.  If  with  the 
former,  it  is  taken  up  at  one  end  on  the  point 
of  the  instrument,  and  passed  to  the  bottom  of  the 
cavity;  and  that  portion  within  the  cavity  is  then 
pressed  firmly  against  the  wall  where  it  is  desirable 
to  be<nn  the  filling.  There  is  no  definite  uniform 
point  in  the  cavities  at  which  to  begin  the  introduc- 
tion of  the  gold ;  usually,  however,  in  crown  cavities 
of  the  molars,  at  the  posterior  wall.  At  whatever 
point  the  filling  is  commenced,  the  cavity  should  be 
so  formed  that  it  will  retain  in  position  the  first  por- 
tion of  gold  introduced ;  and  this  may  be  done  by  form- 
ing a  little  pit  or  groove  for  its  reception.  This  is  a 
particular  that  cannot  with  impunity  be  neglected. 
The  gold  should  never  change  its  position  after  it  is 
pressed  to  the  wall  of  the  cavity  ;  for  its  position 
cannot  be  changed,  except  at  a  sacrifice  of  the  adapta- 
tion, after  it  is  condensed.  The  end  of  the  roll  being 
placed  in  the  cavity,  it  is  seized  far  enough  without 
the  cavity  to  form  a  fold   that  will   extend   to   the 


INTRODUCTION   OF   THE    FILLING.  191 

bottom,  and  protrude  about  one  line  beyond  the 
border  of  the  orifice.  This  fold  is  pressed  firmly 
upon  the  preceding  portion  of  gold  and  adjacent  walls. 
Thus  fold  after  fold  is  introduced,  passed  to  the  bot- 
tom of  the  cavity,  and,  protruding  from  the  orifice, 
consolidated  firmly:  each  portion  as  it  is  introduced 
should  be  well  adapted  to  the  walls  of  the  cavity 
and  the  preceding  portion  of  the  filling. 

It  is  important  to  obtain  as  complete  an  adaptation 
of  the  filling  to  the  walls  of  the  cavity  as  possible  ; 
and  in  order  to  accomplish  this,  the  centre  should 
not  be  filled  too  rapidly.  The  gold  is  thus  introduced 
fold  after  fold  till  the  cavity  is  full.  When  it  is  filled 
to  two-thirds  of  its  diameter,  the  gold  should  then  be 
adjusted  to  all  the  remaining  walls  of  the  cavity,  and 
the  last  portions  of  gold  introduced  somewhere  in 
the  body  of  the  filling,  certainly  not  next  to  any  wall 
of  the  cavity.  A  more  thorough  adaptation  of  the 
gold  can  be  made  to  the  walls  of  the  cavity  by  this 
manner  of  arranging  it  than  by  introducing  the  last 
portion  at  one  side  of  the  cavity.  There  is  less  lia- 
bility of  fracturing  a  frail  tooth  by  placing  the  gold 
on  the  walls  first,  and  terminating  the  introduction 
of  it  at  or  near  the  centre  of  the  filling.  It  is  the 
practice  with  some  to  introduce  the  gold  rather 
loosely,  or  without  much  condensing,  and  after  being 
introduced  in  this  manner,  to  condense  by  forcing 
into  it  a  wedge-shaped  instrument  at  various  points, 


192  FILLING   TEETH. 

and  filling  these  perforations  with  small  rolls  ol  gold, 
continuing  to  use  the  wedge-shaped  instrument  as 
long  as  it  can  be  forced  into  the  filling.  This  method 
is  by  no  means  as  efficient  as  that  of  condensing  each 
portion  as  it  is  introduced.  By  the  hitter  plan  the 
filling  can  be  made  uniformly  dense  from  the  surface 
to  the  bottom.  This  cannot  be  done  by  the  use  of 
the  wedge-shaped  instrument;  it  will  compress  most 
at  its  largest  diameter,  that  is,  at  the  surface  of  the 
filling. 

In  no  filling,  even  when  the  walls  of  the  cavity 
are  parallel,  will  a  uniform  density  throughout  be  ob- 
tained by  perforating  with  the  wedge-shaped  instru- 
ment. The  filling  would  be  most  dense  at  the  sur- 
face, and  gradually  less  so  all  the  way  to  the  bottom. 
This  method  is  objectionable  for  condensing  the  fill- 
ings on  the  masticating  surfaces  of  the  molars ; 
for  in  the  act  of  mastication  the  inner  portion  would 
yield,  the  surface  of  the  filling  would  be  crowded 
down  into  the  cavity,  and  the  dentine  within  the 
orifice  become  exposed,  and  decay  be  the  result.  In 
proximate  fillings,  this  objection  would  not  have  the 
same  force.  In  pressing  an  instrument  of  a  wedge 
form  into  a  filling  with  sufficient  force  to  condense 
the  mass,  there  would  be  great  danger  of  breaking 
a  weak  wall  of  the  cavity.  The  principal  pressure 
is  lateral,  and  would  consequently  come  upon  the 
side  of  the  tooth. 


INTRODUCTION   OF   THE    FILLING.  193 

Iii  crown  cavities  of  the  molars,  where  there  is  any 
considerable  inward  expansion  of  the  cavity,  that 
method  of  condensing  would  be  wholly  inefficient;  it 
would  not  render  the  inner  portion  dense  enough  to 
support  the  surface  of  the  plug,  and  it  would  be 
forced  down,  and  necessarily  be  loose.  In  filling  the 
proximate  cavities  of  the  incisors,  it  is  very  objec- 
tionable on  account  of  the  great  liability  of  break- 
ing the  inner  and  outer  walls,  which  are  usually 
quite  thin. 

In  preparing  the  foil  for  filling,  some  operators 
tear  off  the  foil  in  irregular  pieces,  and  form  these 
into  little  balls  or  pellets,  round  and  loosely  rolled, 
corresponding  in  size  with  the  cavity  to  be  filled. 
These  pellets  are  placed  in  the  bottom,  if  a  crown 
cavity,  and  at  one  side  if  a  proximate  cavity,  and  con- 
densed with  a  sharp-pointed  instrument,  attaching 
one  pellet  to  another  till  the  cavity  is  full.  This 
mode  is  not  so  good  as  that  previously  referred  to, 
unless  the  gold  is  in  a  condition  to  weld  perfectly ; 
there  is  no  continuous  portion  from  the  bottom  to 
the  orifice  of  the  cavity,  and  the  outer  portions  are 
liable  to  become  detached.  Both  of  these  methods 
of  arranging  the  gold  are  objectionable  in  one  par- 
ticular, namely,  the  irregularity  of  the  leaves  of  the 
foil ;  these  are  placed  in  the  cavity  without  regard 
to  regularity,  and  the  consequence  is  that,  without 
it   care,  far   Less   gold  will  be  introduced  than  by 

13 


194  FILLING    TEETH. 

some  other  arrangement.  Much  more  difficulty  is 
experienced  in  obtaining  a  uniform  and  equal  density 
than  when  the  laminae  are  placed  smoothly  together. 
Another  method  of  preparing  the  foil  is  to  fold  it 
into  from  four  to  twelve  thicknesses,  then  cut  off 
strips  in  width  corresponding  to  the  diameter  of  the 
cavity.  The  strip  thus  prepared  is  introduced  in  the 
same  manner  as  the  roll,  except  that  as  each  (bid  is 
inserted,  it  is  placed  smoothly  against  the  preceding 
portion,  and  kept  smooth  and  free  from  wrinkles. 
By  this  arrangement  very  little  force  is  required  to 
bring  the  folds  in  perfect  contact.  Some  care  and 
skill  will  be  necessary  to  bring  the  instrument  to 
bear  upon  the  whole  surface  of  the  fold.  More  gold 
can  be  put  into  a  cavity  in  this  manner  than  in  rolls 
or  pellets,  unless  these  are  used  in  small  portions  and 
condensed  thoroughly  as  they  are  put  in. 

Cylinder  or   Block  Filling. 

Another  and  in  some  respects  far  preferable 
method,  is  filling  with  cylinders  or  blocks.  Some 
of  the  advantages  of  this  method  over  that  just  de- 
scribed are  the  following:  the  filling  can  be  intro- 
duced far  more  rapidly  ;  and  the  laminae,  or  leaves  of 
foil,  take  a  more  perfect  position  in  the  cavity,  and 
consequently  the  structure  of  the  filling  is  better. 
The  form  of  the  cavity  should  be  much  the  same  as 


CYLINDER   OU    BLOCK    FILLING.  195 

that  for  any  other  method  of  filling  ;  there  should  be 
some  retaining-point  so  situated  that  the  first  block, 
or  blocks,  can  be  fixed  firmly  in  place,  so  that  there 
will  be  no  liability  of  loosening  during  the  subsequent 
part  of  the  process.  It  is  important  to  have  such  an 
arrangement,  as  otherwise  it  would  be  necessary  to 
employ  an  instrument  in  the  left  hand  to  retain  the 
first  blocks  in  situation,  till  enough  were  introduced 
to  bind  the  whole  by  pressure  upon  two  opposite 
points  in  the  cavity. 

Forming  Block*. — For  forming  blocks,  use  any 
number  of  foil  that  may  be  desired,  usually,  No.  4 
or  6,  and  either  lay  four  or  six  sheets  together,  or 
fold  a  single  sheet  into  that  number  of  thicknesses ; 
then  cut  off  from  the  sheets  thus  prepared  strips 
about  one-third  to  one-fourth  wider  than  the  depth  of 
the  cavity  to  be  filled  ;  these  are  then  rolled  on  a 
small  three  or  four-sided  broach — the  three-sided  is 
better.  This  instrument  should  be  very  small — no 
larger,  indeed,  than  is  necessary  for  strength.  Its 
sides  should  be  perfectly  smooth,  and  its  angles 
sharp  ;  ordinarily  it  should  not  taper,  or  at  least  but 
slightly.  For  forming  the  conical  blocks,  some  pre- 
fer the  tapered  broaches,  but  they  can  be  as  well 
made  on  the  parallel-sided  instruments.  The  strip 
being  taken  between  the  thumb  and  the  index  finger, 
i-  rolled  on  the  broach  equally,  till  the  block  or  cyl- 
inder is  large  enough,  when  the  strip  is  broken  off. 


196  FILLING    TEETH. 

The  size  of  the  principal  part  of  the  blocks  should  be 
determined  by  the  size  of  the  cavity  to  be  filled.  Dif- 
ferent sizes  and  forms  will  be  required  in  almost  every 
case.  Relatively  large  cylinders  may  be  employed  for 
the  principal  part  of  the  filling.  If  the  walls  of  the 
cavity  are  parallel,  almost  all  the  blocks  may  be  cyl- 
indrical;  but  if  there  is  an  under-dipping  of  one 
or  more  of  the  walls,  the  blocks  adjusted  to  that  par- 
ticular part  should  be  cone-shaped,  corresponding  to 
that  under-dipping.  A  number  of  small  graduated 
cone-shaped  blocks,  of  different  degrees  of  density, 
will  be  required  for  completing  each  filling;  as  the 
aperture  becomes  smaller,  smaller  blocks  will  be 
needed.  The  cone-shaped  blocks  are  formed  by  grad- 
ually running  the  strip  back  from  the  point  of  the 
instrument  as  it  is  wound  on;  greater  or  smaller 
taper  can  be  given  to  it  as  the  strip  is  run  less  or 
more  rapidly  back  from  the  point.  The  density  of 
the  block  can  be  regulated  by  the  firmness  with 
which  the  strip  is  held  between  the  thumb  and 
ringer,  upon  which  it  is  well  to  have  a  suitable  cov- 
ering, to  protect  the  gold  from  the  perspiration  of  the 
hand.  There  are  other  methods  of  forming  blocks. 
Cylinders  and  blocks  are  prepared  by  foil  manufac- 
turers, in  sufficient  variety,  in  respect  to  size,  form, 
and  density,  to  meet  all  cases;  they  should  always 
be  at  hand.  Fig.  85  represents  cylinders  and  blocks 
as  prepared  by  foil  makers.      They  may  be  made 


CYLINDER   OR    BLOCK    FILLING,  197 

square,  by  making  a  great  number  of  folds — fifteen 
to  thirty — and  from  this  cutting  strips  as  before  di- 
rected, and  then  from  these  heavy  strips  cutting  off 
the  blocks  of  the  desired  size,  which  will  then  be  flat 
or  nearly  square.  In  one  respect  these  blocks  are  ob- 
jectionable. The  edges  when  they  have  been  cut 
off  are  rendered  dense  by  the  action  of  the  shears, 
so  that  they  do  not  possess  the  uniform  density  or 
consistence  of  the  rolled  blocks  or  cylinders  and  it 
is  impossible  to  adapt  them  as  perfectly  to  the  walls 
of  the  cavity,  or  to  one  another.    This  objection,  how- 

Fjg.  85. 


o^  ©  ■§  19  ED 


ever,  may  be  obviated  by  cutting  off  the  blocks  with 
a  very  fine  knife,  such  as  is  used  by  the  foil  makers. 
A  good  method  of  making  pellets  is  to  form  with  a 
napkin,  a  sheet,  or  part  of  a  sheet  of  foil,  of  an}' 
desired  thickness,  into  a  roll  of  proper  density,  and 
cut  from  it  blocks  or  pellets,  the  length  of  which 
may  be  indicated  by  the  size  of  the  cavity  to  be  filled. 
These  are  liable  to  the  same  objection  as  those  last 
mentioned,  the  shears  hardening  them  when  they 
are  cut  off.  They  are  subject  to  the  additional 
objection,  that   the  folds  of  foil  are  not  as  regular 


198  PILLING  TEETH. 

as  by  either  of  the  other  methods.  But  by  proper 
manipulation,  with  the  gold  prepared  in  this  manner, 
superior  fillings  may  be  made.  Another  method  of 
preparing  blocks  is  by  cutting  a  sheet  of  foil  into  two 
or  three  pieces,  then  rolling  them  diagonally  on  a 
steel  wire  or  rod ;  the  size  of  this  wire  will  be  deter- 
mined by  the  required  length  of  the  blocks ;  as  there 
should  be  blocks  of  different  lengths,  the  wires  should 
be  of  different  sizes,  and  range  from  No.  2  to  No.  12 
of  White's  bur  gauge  plate.  The  size  of  the  wire  will 
be  determined  by  the  depth  of  the  cavity.  The  wire 
being  withdrawn,  the  roll  is  compressed  to  a  strip. 
These  strips  are  now  rolled  squarely  upon  a  No.  20 
steel  wire,  the  size  of  the  cylinder  being  determined 
by  the  size  and  form  of  the  cavity  to  be  filled. 
These  may  be  used  either  in  their  cylindrical  form 
or  compressed  and  doubled.  The  cavity  formed  and 
the  blocks  prepared,  the  next  step  is  their  introduc- 
tion. 

Introducing  the  Blocks. — For  placing  the  gold  into 
the  cavity,  the  plugging  pliers  are  required,  the 
points  of  which  should  be  curved,  so  as  to  make  the 
most  direct  approach  to  the  cavity.  The  points,  too, 
if  properly  formed,  may  be  used  to  some  extent  for 
condensing  the  gold.  All  things  being  ready,  the 
cavity  secured  against  the  encroachment  of  moisture 
from  the  saliva  and  breath,  the  left  hand  should  be 
employed  to  keep  the  rubber  and  the  soft  parts  of 


CYLINDER   OR    BLOCK    FILLING.  199 

the  mouth  in  position.  If  there  is  an  angle,  a  small 
block  should  be  first  introduced  with  the  pliers  into 
the  proper  position,  one  eud  upon  the  bottom  of  the 
cavity,  and  the  other  protruding  from  the  orifice,  and 
pressure  then  be  made  to  consolidate  it,  and  force  it 
into  its  position  against  the  wall  of  the  cavity.  This 
may  be  done  with  the  pliers,  or  better  with  the 
instrument  represented  b}^  Fig.  34.  The  part  of  the 
instrument  brought  to  bear  upon  the  gold  should  be 
roughened  either  longitudinally  or  transversely,  so 
that  a  proper  surface  may  be  left  for  the  reception  of 
the  succeeding  portions.  The  largest  blocks  are  then 
introduced  and  consolidated  successively  as  described, 
the  end  of  each  left  protruding  till  the  cavity  is 
filled  ;  each  portion  as  it  is  introduced  should  be  per- 
fectly condensed.  The  gold  should  be  filled  in  at 
the  sides  of  the  cavity  in  advance  of  the  centre,  thus 
being  disposed  round  the  walls  till  it  meets  at  a 
point  opposite  the  place  of  beginning;  and  thus  the 
gold  is  adapted  to  all  the  walls  of  the  cavity  before 
it  is  entirely  filled,  the  last  portions  being  introduced 
somewhere  near  the  centre  of  the  filling.  As  the 
cavity  diminishes  by  the  introduction  of  the  gold,  the 
small  and  more  dense  blocks  will  be  required;  these 
should  he  forced  in  and  condensed,  by  crowding  the 
instrument  (Fig.  30)  down  against  the  side  of  the 
cone  Some  operators  terminate  the  filling  against 
the  wall  of  the  cavity,  forcing  down  the  blocks  and 


200  FILLING    TEETH. 

compressing  as  above,  till  it  is  full.  By  this  method 
there  is  danger  of  fracturing  the  tooth,  breaking 
down  the  wall  of  the  cavity,  where  the  filling  is  ter- 
minated. Another  method  is  to  fill  up  tin-  cavity 
principally  with  blocks,  ami  to  put  in  the  lasl  part  of 
the  filling  in  the  strip,  filled  in  from  tin-  bottom  t<> 
the  orifice.  The  objection  to  this  method  is.  that 
unless  adhesive  foil  is  employed,  the  portion  inserted 
in  the  strip  is  liable  to  he  displaced,  and  in  this  way 
the  whole  filling  become  destroyed. 

Another  method  of  arranging;  this  kind  of  filling, 
particularly  when  the  bottom  of  the  cavity  is  irreg- 
ular, is  to  make  a  large,  flat  pellet,  condense  it  firmly 
to  the  bottom,  and  set  the  blocks  upon  this  for  a 
foundation.  By  this  method  there  is  a  more  perfect 
adaptation  of  the  gold  to  the  bottom  of  the  cavity, 
than  by  placing  the  ends  of  the  blocks  down  upon  an 
uneven  surface.  After  the  gold  is  all  introduced,  a 
small-pointed  plugger  must  be  passed  over  the  entire 
surface,  to  consolidate  the  protruding  portions.  These 
protruding  portions  should  he  sufficient  to  make  the 
surface,  after  being  condensed,  perfectly  flush  with 
the  border  of  the  cavity,  for  a  depression  here  is 
fatal  to  a  complete  finish,  except  by  the  addition  of 
cohesive  gold.  After  the  condensation  with  the  finely 
serrated  points,  then  the  blunt,  smooth,  polished, 
points  should  be  used  with  the  mallet  all  over  the 
surface  of  the  filling,  then  the  files,  burs,  stones,  etc., 


PELLETS.  201 

of  the  various  grades  should  be  used  to  complete  the 
finish. 

Dr.  Badger  described  a  method  of  filling  a  small 
cavity  on  the  posterior  proximate  portion  of  a  second 
molar,  the  third  molar  gone.  The  cavity  is  formed 
with  a  bur  drill.  A  cylinder  is  then  formed  in  the 
usual  manner,  and  forced  through  a  series  of  holes  in 
a  drawplate,  down  to  the  size  of  the  bur  with  which 
the  cavity  is  prepared.  The  block  is  thus  rendered 
quite  dense.  The  cavity  is  then  dried,  and  the  block 
forced  into  it,  which  it  exactly  fits,  protruding  a  little 
from  the  orifice.  This  block  is  pierced  in  the  centre 
with  a  sharp  instrument,  and  a  small  dense  roll 
forced  into  it ;  all  is  then  condensed,  and  finished  in 
the  usual  manner. 

Pellets. — Pellets  made  by  rolling  fragments  or 
pieces  of  foil  between  the  thumb  and  fingers  are  used 
by  some  operators,  and  with  them  they  profess  to 
make  as  good  filling  as  by  any  other  method.  They 
are  made  of  various  sizes,  and  packed  into  the  cavity 
with  sharp-pointed  or  serrate-pointed  instruments. 
The  pieces  may  thus  be  very  solidly  worked  together, 
and  a  good  filling  made,  provided  the  pellets  are  not 
too  large;  they  should  be  small  enough  to  permit  the 
point  or  points  to  work  through  them  into  the  preced- 
ing portions.  Some  operators  use  pellets  and  crys- 
tal gold  together.  This  may  do  very  well  if  the  co- 
hesive property  of  the  gold  is  employed  ;  but  in  that 


202  FILLING    TEETH. 

case,  either  form  of  the  material  would  answer  alone. 
There  cannot  be  as  much  gold  put  in  by  pellets  as  by 
blocks  or  cylinders  well  adjusted. 

Cohesive  Foil. — By  this  is  understood  that  condi- 
tion of  gold  foil  in  which  the  leaves  unite  readily 
and  firmly  together.  This  property  of  cohesion  is 
possessed  in  the  greatest  degree  by  properly  manu- 
factured foil,  immediately  after  annealing.  Not  that 
annealing  imparts  any  new  property  to  the  gold,  but 
it  removes  obstacles  to  the  manifestation  of  a  prin- 
ciple possessed  by  all  gold  under  favorable  circum- 
stances. It  is  now  about  twenty-five  years  since  this 
property  was  first  employed  in  gold  foil  for  filling 
teeth.  To  Dr.  R.  Arthur  is  due  the  credit  of  first 
directing  the  attention  of  the  profession  to  it,  as 
being  available  for  filling  teeth.  He  not  only  did 
this,  but  he  entered  most  fully  into  the  details  of  the 
manipulations,  instruments,  etc.,  pertaining  to  this 
mode  of  operation.  Almost  all  recently-prepared 
gold  foil  possesses  this  property  to  a  greater  or  less 
degree  ;  there  are  methods  of  preparing  it,  however, 
by  which  it  possesses  it  more  fully ;  all  recently 
annealed  foil  is  cohesive.  If  the  foil  is  in  this  con- 
dition when  we  wish  to  use  it,  nothing  further  is 
required  in  the  way  of  preparation.  But  if  it  is  not 
cohesive, — as  almost  all  foil  is  not,  especially  if  it  has 
been  much  exposed  to  the  influence  of  the  atmo- 
sphere,— it  will  require   to  be  made  so  by  some  pro- 


COHESIVE    FOIL    FILLING.  203 

cess.     There  are  two  methods,  either  of  which  will 
well  accomplish  the  object. 

The  one  most  frequently  employed  is  that  of  heat- 
ing the  gold,  either  in  the  sheet,  in  the  roll,  or  in 
fragments,  over  the  flame  of  a  spirit-lamp,  almost  or 
quite  to  a  red  heat ;  if  in  the  sheet,  it  should  be  laid 
upon  a  piece  of  wire  gauze,  and  passed  over  the 
flame  of  the  lamp  for  a  moment  or  two  ;  if  in  the 
roll,  it  may  be  taken  in  the  centre  with  fine  pliers 
and  passed  rapidly  through  the  flame.  But  if  the 
gold  is  in  the  form  of  pellets,  blocks,  or  cylinders,  or 
small  pieces  of  any  shape,  it  may  be  taken  up  with 
the  pliers  and  passed  rapidly  through  the  flame  of  a 
spirit-lamp,  till  all  foreign  substance  is  burned  or 
driven  from  it.  Or  it  may  be  placed  on  a  sheet  of 
mica,  which  is  adjusted  over  a  flame,  and  then 
brought  to  a  proper  temperature. 

There  are  different  methods  of  using  gold  in  this 
condition  ;  but  in  general  the  cavity  should  be  formed 
about  as  for  the  other  methods  of  filling,  except  that 
at  some  point  or  points  the  cavity  should  be  formed 
s<>  as  to  retain  firmly  the  first  portion  of  gold  intro- 
duced ;  such  anchorage  should  be  located  with  refer- 
ence to  convenience,  and  the  strength  of  the  tooth. 
The  first  portion  of  gold  should  be  a  little  pellet ; 
this,  forced  into  these  retaining  spaces,  serves  as  a 
foundation  for  the  remaining  portion  of  the  filling. 
\)v.   Arthur's   method  is,  then   to   tear  off  fragments 


2l  '  I  FILLING   TEETH. 

from  the  sheet,  and  pass  it  into  the  cavity  without 
folding,  and  condense  it  with  an  instrument  of  finely 
serrated  point,  so  that  it  not  only  unites  by  cohesion, 
but  is  worked  into  the  surface  of  the  preceding  por- 
tion of  gold  ;  and  in  this  manner  portion  after  por- 
tion is  introduced  and  condensed,  until  the  cavity  is 
full.  The  filling  may  be  commenced  in  any  part  of 
the  cavity  that  is  most  convenient;  in  many,  as  in 
crown  cavities  of  the  molars,  at  the  bottom,  and  filled 
to  the  orifice.  In  putting  in  the  gold,  it  should  dur- 
ing its  introduction,  be  kept  fuller  about  the  walls  of 
the  cavity  than  in  the  centre  ;  by  this  means  the 
adaptation  will  be  most  perfect  to  the  walls,  and 
there  will  be  no  liability  of  clogging  in  the  centre. 
The  gold  may  thus  be  built  up  to  any  desired  extent 
if  the  filling  is  kept  dry ;  moisture  is  fatal  to  its  co- 
hesion. 

Others  use  the  cohesive  gold  in  a  different  manner. 
To  Dr.  Blakesley  belongs  the  honor  of  first  detail- 
ing the  following  plan  :  The  sheet  of  gold  may  be 
folded  or  not,  at  the  pleasure  of  the  operator,  and  then 
each  sheet  cut  into  from  two  to  six  strips,  and  each 
of  these  formed  into  a  loose  roll  between  the  thumb 
and  fingers.  These  should  now  be  passed  through 
the  flame,  as  already  described,  then  cut  into  little 
blocks  or  pellets  of  various  sizes  ;  these  to  be  regu- 
lated by  the  size  of  the  roll  and  the  cavity  to  be 
filled.     For  the   introduction   of  the  gold   thus  pre- 


COHESIVE    FOIL    FILLING.  205 

pared,  about  three  sizes  of  instruments  are  required, 
those  having  finely  serrated  points  being  preferable. 
As  to  the  size  of  these  points,  Dr.  Blakesley  remarks, 
"They  should  just  enter  respectively  Nos.  22,  24, 
and  26  of  the  wire-gauge."  A  larger  than  either  of 
these,  however,  is  desirable  for  many  cases.  As  be- 
fore, the  filling  may  be  commenced  at  the  bottom 
of  a  cavity,  or  at  one  side,  if  desirable,  with  a 
pellet  sufficiently  large  to  be  set  firmly  into  the  re- 
taining space.  Then  take  up  the  small  pellets  or 
blocks  upon  the  point  of  the  plugging  instrument, 
and  place  them  exactly  in  the  desired  position,  and 
consolidate  them  thoroughly,  building  up  next  to  the 
wall  all  around  higher  than  the  centre,  with  the 
smaller  pieces  filling  up  the  little  corners  and  inter- 
stices, for  which  manipulation  the  smaller  points  will 
be  required.  The  gold  is  then  packed  in  till  the 
cavity  is  full,  when  it  is  finished  as  usual.  Another 
method  is  to  tear  off  fragments  from  the  sheet  and 
roll  these  into  round  pellets,  and  fill  with  these  with 
1 1  j < -  same  instruments  and  upon  the  same  principle 
as  above  described.  But  by  this  method  it  is  difficult 
to  make  a  perfect  filling;  the  gold  is  liable  to  clog  in 
the  cavity  and  fail  in  adaptation. 

Cohesive  gold  must  be  consolidated  as  it  is  intro- 
duced, for,  if  a  cavity  is  full,  it  is  very  difficult  then 
t,,  condense  it  more,  even  though  the  consolidation 


206  PILLING   TEETH. 

is  but  partial;  and  the  same  is  true  to  some  extent, 
of  non-cohesive  foil. 

The  Mallet. 

In  the  year  1860,  Dr.  W.  H.  Atkinson  introduced 
to  the  dental  profession  the  mallet  for  the  purpose 
of  condensing  gold  in  filling  teeth.  This  effected 
quite  a  change  in  the  theory  and  practice  of  this 
part  of  the  work.  Prior  to  this  period  it  was  accom- 
plished entirely  by  the  pressure  or  force  exerted  by 
the  hand.  There  was  very  considerable  diversity  of 
opinion  as  to  the  best  mode  of  this  manipulation, 
some  maintaining  that  great  force  is  always  required 
to  make  a  filling  sufficiently  dense,  assuming  that  it 
is  better  to  use  comparatively  large  points,  great 
pressure  and  rapid  execution,  thus  securing  the  ut- 
most economy  of  time,  both  to  the  operator  and  pa- 
tient. Others  entertain  the  opinion  that  with  smaller 
points,  less  pressure,  and  greater  time,  a  more  definite 
and  satisfactory  result  is  attained. 

Notwithstanding  the  diversity  of  opinion  and  prac- 
tice upon  this  subject,  we  would  suggest  that  young 
operators,  at  least,  should  bear  in  mind  that  in  so 
important  a  matter  as  filling  teeth  efficiency  should 
never  be  sacrificed  to  rapidity. 

This  method  is  especially  applicable  and  effective  for 
the  condensation  of  cohesive  gold,  and,  indeed,  gold  in 


THE   MALLET.  207 

an  v  form,  when  the  aim  is  to  condense  each  portion 
as  it  is  introduced.  A  more  thorough  condensation 
is  made  by  the  use  of  the  mallet  than  is  possible  by 
the  hand  alone;  greater  precision  of  manipulation  is 
attainable;  it  is  easier  for  the  operator,  and  usually 
less  unpleasant  to  the  patient. 

The  character  of  the  results  in  the  use  of  this  in- 
strument depends  much  upon  the  skill  of  the  assist- 
ant. It  requires  time,  care,  and  patience  to  familiar- 
ize an  assistant  with  the  use  of  the  mallet.  The 
plugger  should  be  held  firmly  in  position  by  the  op- 
erator, and  receive  the  stroke  squarely  upon  the  end  ; 
it  should  be  a  sharp,  springing  tap.  Very  much  de- 
pends upon  the  character  of  the  blow;  a  dead,  heavy 
stroke  will  not  unite  the  gold  as  it  should  be.  It  is 
important  that  the  assistant  be  able  to  follow  the  in- 
dications of  the  operator  without  loss  of  time.  Many 
assistants  are  disposed  to  give  time  strokes  instead  of 
following  indications,  which  are  not  admissible  ex- 
cept in  very  simple  cases. 

In  order  to  avoid  the  employment  of  an  assistant 
and  to  place  the  strokes  of  the  instrument  more  under 
the  control  of  the  operator,  various  forms  of  auto- 
matic mallet  pluggers  have  been  invented  and  con- 
structed. Two  or  three  principles  embrace  the  whole, 
though  many  different  forms  have  been  made.  Those 
operated  by  tie-  action  of  spiral  springs  have  been 
the   more   common;  tin-   objection    to  almost  all  of 


208  FILLING    TEETH. 

these  is,  that  the  stroke  lacks  the  desired  elasticity. 
This  class  of  instruments  is  represented  in  general 
aspect  by  Fig.  86. 

This  instrument  was  invented  by  Dr.  I.  A.  Sal- 
mon, and  is  one  of  the  best  of  this  form;  it  operates 
well  in  the  hands  of  those  who  become  familiar 
with  it. 

An  instrument  was,  some  years  ago,  made  by  Dr. 
S.  B.  Palmer,  in  which  the  force  of  the  blow  is  placed 
completely  under  the  control  of  the  operator  while  it 

Fig.  86. 


is  being  used.  The  operation  of  this  instrument  is 
perhaps  less  objectionable,  in  respect  to  the  character 
of  the  stroke,  and  its  control  by  the  operator,  than 
any  other  as  yet  employed.  Any  of  these  instru- 
ments are  valuable  in  the  hands  of  those  who  become 
familiar  with  them. 

During  the  last  few  years  efforts  have  been  made 
to  operate  the  mallet  by  various  motors.  The  first 
attempt  in  this  direction  was  by  Dr.  G.  W,  Bonwill, 
by  the  application  of  galvano-electricity.  The  first 
machines  were  very  crude  and  unsatisfactory;  but 
by  improvements  made  from  time  to  time,  the  in- 
strument is  quite  efficient  in  the  hands  of  those  fa- 
miliar with  it. 


CRYSTAL   OR   SPONGE   GOLD. 

A  mallet  has  been  invented  and  constructed  by 
Professor  T.  L.  Buckingham,  designed  to  be  attached 
to  and  operated  by  the  dental  engine.  It  is  more 
under  the  immediate  control  of  the  operator  than 
most  of  the  automatic  mallets  in  use.  This  is  highly 
prized  by  many.  The  pneumatic  mallet  was  devised 
by  Dr.  W.  H.  Jackson.  This  consists  of  an  ingenious 
and  yet  simple  application  of  air  as  a  motor.  For  a 
description  of  each  of  these,  with  illustrations,  see 
Appendix  of  this  work,  Section  C. 

Crystal  ob  Sponge  Gold. 

The  form  of  the  cavity  for  crystal  gold  filling 
should  be  much  the  same  as  that  described  for  other 
fillings,  except  that  the  same  care  is  not  neces-ary  for 
special  retaining-points,  for  the  first  portion  of  g 
crystal  scold  that  is  introduced  into  the  cavity  will  at- 
tach  to  the  walls  without  any  such  provision.  Such 
a  form  should  be  given,  however,  as  to  secure  the  first 
piece  firmly  in  place.  The  gold  should  be  cut  or 
broken  into  pieces  corresponding  in  size  v>  the  cavity, 
hat  they  will  enter  freely  into  it. 

The  filling  may  be  commenced  upon  the  bottom  of 
the  cavity,  or  upon  one  of  it-  sides;  such  a  point  al- 
ways being  selected  as  will  most  effectually  retain  the 
gold    in   place.     The   j  -  should  be  of  var 

3,  the  first  one  as  large  as  can  be  used  freely  in  the 

14 


210  PILLING    TEETH. 

cavity,  and  smaller  ones  for  condensing  more  thor- 
oughly, and  all  should  be  serrated.  The  blocks  may 
be  taken  up  on  the  point  of  the  plugger,  or  perhaps 
better  with  the  pliers,  and  passed  to  the  proper  posi- 
tion iu  the  cavity,  and  there  condensed.  The  sharp 
serrated  point  leaves  the  surface  in  good  condition  for 
the  reception  of  the  next  piece.  The  gold  should  be 
packed  to  the  walls  of  the  cavity  a  little  in  advance  of 
the  centre,  so  that  its  adaptation  may  be  more  com- 
plete. In  this  manner  the  filling  is  built  up  as  much 
as  is  desirable,  if  it  is  kept  dry,  and  unless  it  is,  cohe- 
sion is  verv  much  diminished  or  lost  altogether. 

The  gold,  after  it  is  cut,  is  passed  through  the  flame 
of  a  spirit-lamp,  to  anneal  it,  and  dispel  all  foreign 
substances.  It  should  in  no  case  be  brought  above  a 
perceptible  reel  heat,  and  usually  not  to  that  point ; 
it  should  be  done  carefully,  so  as  not  to  fuse  any  of 
the  particles,  as  that  would  impair  their  facility  of 
cohesion  in  this  process.  Small  portions  are  often  re- 
quired to  fill  up  small  interstices,  or  notches. 

In  crown  cavities,  the  filling  should  begin  at  the 
bottom ;  in  proximate  cavities,  at  the  cervical  wall. 
By  introducing  the  gold  in  this  manner,  the  pressure 
is  made  on  a  line  with  the  axis  of  the  tooth,  which  is 
an  important  consideration.  The  surface  of  the  filling 
should  be  made  to  conform  to  that  of  the  lost  portion 
of  the  tooth ;  this  can  always  be  done  except  where 
the  tooth  is  largely  broken  away,. and  even  then  very 


CRYSTAL   OK   SPONGE   GOLD.  211 

much  may  be  accomplished  in  many  cases  to  restore 
the  lost  form  ;  that  will  depend,  however,  upon  the 
method  of  using  the  gold,  and  the  security  of  the  at- 
tachment for  it.  In  crown  fillings  of  the  molars  and 
bicuspids,  the  antagonism  of  the  teeth  must  be  regarded ; 
they  should  be  formed  for  the  reception  of  the  cusps 
of  the  opposing  tooth.  Proximate  fillings  should  usu- 
ally be  convex  ;  yet  many  good  fillings  of  this  class 
are  made  with  a  surface  perfectly  plain  with  the  bor- 
ders of  the  cavity.  The  borders  of  the  filling,  however, 
are  better  protected  when  it  is  somewhat  convex. 

( Crystal  gold,  of  j^erfect  character,  presents  to  the 
walls  of  the  cavity  a  surface  better  calculated  to  be  re- 
tained than  foil  in  any  of  its  forms ;  though  cohesive 
foil  possesses  this  advantage  to  a  greater  extent  than 
foil  in  any  other  condition.  The  points  and  edges  of 
the  crystals  are  brought  in  contact  with  the  walls,  and 
take  a  firmer  hold  upon  the  dentine. 

In  forming  crystal  gold  into  a  solid  mass,  two  prin- 
ciples are  operative  :  cohesion  acts  upon  it  as  potentially 
;i-  upon  gold  in  any  other  form,  and,  in  addition,  there 
is  the  interlacing,  or  locking,  of  the  crystals  with  one 
another;  so  that  a  more  perfect  union  of  the  different 
portions  of  which  a  filling  is  composed  is  obtained  with 
crystal  gold  than  with  foil.  Yet  good  cohesive  foil, 
when  properly  manipulated,  attains  almost  the  same 
condition. 

It  us  important  to  keep  the  gold  perfectly  frac  from 


212 


PILLING   TEETH. 


moisture  while  being  introduced  and  consolidated  ;  for 
moisture  instantly  destroys  its  cohesive  property.  And 
the  more  complete  the  exclusion  of  moisture  from  the 

cavity  during  the  process,  the  better  for  the  success  of 
the  operation.  The  surface  of  every  filling  should  be 
consolidated  for  finishing  before  it  is  allowed  to  become 
moist,  for  if  it  becomes  saturated  with  moisture  before 
consolidation,  it  is  impossible  to  make  a  perfect  finish. 


Fig.  87. 


(7 


There  should  always  be  gold  enough  superadded  to  in- 
sure this ;  and  the  consolidation  of  the  surface  should 
be  effected  with  a  burnisher  of  the  proper  form,  used 
with  the  mallet,  consolidating  the  entire  surface  as 
thoroughly  and  smoothly  as  possible,  exercising  great 
care  about  the  borders  of  the  filling.  Fig.  87  repre- 
sents the  forms  of  the  burnishers  suitable  for  almost 
all  cases. 


FINISHING    FILLINGS.  213 


Finishing  Fillings. 


The  method  of  finishing  a  filling,  and  the  manipu- 
lation required,  will  depend  somewhat  on  its  locality. 
When  the  filling  has  been  thoroughly  consolidated 
over  all  the  surface,  and  especially  all  round  its  border, 
the  file  may  be  applied  to  dress  off  any  projecting  por- 
tion, and  render  it  smooth.  In  consolidating  the  sur- 
face, an  instrument  should  be  used  that  would  not 
pit  it,  and  the  file  or  finishing  bur  should  remove  all 
indentations.  The  work  of  these,  however,  should  be 
but  partially  performed  at  first,  and  the  surface  bur- 
nished again.  To  obtain  the  most  perfect  finish,  the 
surface  should  be  brought  to  a  uniform  consistence ; 
and  this  condition  cannot  be  reached  by  the  use  of 
sharp-pointed  instruments,  nor  fully  by  that  of  the 
blunt  plugger  at  the  first  effort,  but  by  the  alternate  use 
of  the  file,  corundum  wheel  or  cone,  the  blunt  condenser, 
with  the  mallet,  and  the  burnisher.  A  coarse  corundum, 
or  bur  should  be  employed  in  this  part  of  the  process ; 
l»i it  when  the  filling  is  dressed  sufficiently,  and  in  good 
condition,  the  fine  corundum,  Hindostan  and  Scotch 
Btone  -hould  be  used  alternately  with  the  burnisher, 
till  a  perfectly  uniform  surface  is  obtained.  In  all 
-  after  tin-  stone  has  been  applied,  the  plug  should 
l»<-  washed  oil'  with  a  brush,  to  remove  all  detached 
pieces  of  gold,  before  the  burnisher  is  put  upon  it ; 
and  after  the  Scotch  or  Arkau sas  stone,,  slips  of  the 


21  1  PILLING    TEETH. 

proper  form,  used  with  the  port-polisher,  or  very  fine 
pumice,  should  be  employed  to  remove  the  file-marks. 
The  pumice  may  be  applied  with  water  on  a  strip  of 
chamois  skin,  a  piece  of  linen  tape,  or  a  stick  of  son 
wood — the  latter  being  the  mosl  convenient,  as  it  can 
be  used  with  one  band — shaped  to  suit  any  place  or 
position.  Emery  cloth  of  every  requisite  grade  of 
fineness  is  now  obtainable  ;  this  may  be  cut  into  strips 
of  any  desired  width.  It  is  very  efficient  for  finishing 
all  fillings  in  the  proximate  portions  of  the  teeth. 

After  the  stone  or  the  pumice  has  accomplished  its 
work,  and  the  filling  has  beeo  thoroughly  washed,  a 
fine  burnisher,  with  a  solution  of  castile  soap,  may 
be  used  to  give  the  finish.  The  burnisher  should  be 
of  the  best  cast  steel,  and  of  high  temper  and  fine 
polish.  Considerable  skill  is  requisite  to  give  the  best 
effect  with  the  burnisher;  it  should  pass  smoothly 
and  gently  over  the  surface,  throughout  its  whole 
extent,  and  in  parallel  lines,  with  a  pressure  neither 
too  light  nor  too  heavy.  It  should  also  be  applied 
very  thoroughly  upon  any  portion  of  the  tooth  about 
the  border  of  the  filling  that  may  have  been  cut  by 
the  file  or  any  other  instrument.  Indeed,  quite  as 
much,  if  not  more,  care  should  be  exercised  upon  this 
a-  upon  the  plug  itself:  it  should  be  polished  as 
smooth  as  the  enamel,  if  possible,  for  the  more  nearly 
perfect  it  is  in  this  respect,  the  better  will  it  resist  the 
action  of  the  deleterious  agent-. 


FINISHING   FILLINGS.  215 

This  method  of  finishing  gives  to  the  filling  a  per- 
fect metallic  lustre,  which  under  some  circumstances, 
is  objectionable.  Two  otber  methods  are  in  use: 
After  the  burnisher  has  been  applied,  as  above,  the 
buff  or  tape,  with  rouge,  may  be  employed,  by  pass- 
ing it  rapidly  over  the  rilling,  till  the  metallic  lustre 
is  destroyed,  or  deadened,  so  as  not  to  reflect  the  light 
as  before,  thus  leaving  a  very  desirable  finish  ;  and 
the  other  method  is,  to  stipple  over  the  surface  of 
the  burnished  filling  with  the  end  of  a  piece  of  hard 
wood, — sandalwood  is  recommended, — charged  with 
finely-pulverized  pumice.  This  gives  a  beautiful, 
velvet-like  surface,  and  is  applicable  to  fillings  in  the 
anterior  portion  of  the  mouth,  where  they  are  ex- 
posed to  view.  Rotten-stone,  applied  either  with 
th<-  buff  or  with  hard  wood,  imparts  a  finish  which, 
although  a  little  different,  is  equal  to  any  of  the 
oth<  T-. 

For  finishing,  some  operators  prefer  to   cut   and 

polish,  instead  of  filing,  stoning  or  burnishing.  But 
neither  so  good  nor  bo  fine  a  finish  can  be  effected  in 
this  way,  and  it  is  probable  that  economy  of  time  and 
labor,  especially  the  latter,  suggested  the  method.  The 
introduction  and  use  of  the  corundum  cones  and 
disks,  cones  of  Hindostan  and  Scotch  stone,  and  the 
wood  con.-  and  buns  (represented  on  pp.  113,  114), 
all  to  !)••  used  with  the  dental  engine,  greatly  facili- 
tate tin-  work  of  finishing,  and  perhaps  accomplish  it 


216  PILLING   TEETH. 

better;  but  greal  care  should  always  be  exercised  in 

the  use  of  these  implements.  In  all  cases  the  filling 
should  have  a  distinct  and  definite  margin ;  the  gold 
should  be  trimmed  off  quite  up  to  the  border  of  the 
cavity,  by  passing  round  it  a  small  sharp  instrument, 
so  as  to  detect  and  pare  down  any  portion  that  might 
overlap  the  tooth  ;  for  if  overlapping  portions  are 
permitted  to  remain,  foreign  substances  will  lodge  be- 
neath, and  induce  decay.  Neglect  in  this  particular 
has  occasioned  the  loss  of  thousands  of  teeth  that 
otherwise  might  have  been  saved.  This  direction 
does  not  apply  to  those  cases  elsewhere  mentioned, 
in  which  it  is  recommended  to  form  a  thick,  firm  over- 
lapping portion,  for  the  protection  of  a  thin  febrile 
border. 

The  subject  of  finishing  is  almost  entirely  over- 
looked by  very  many  operators,  but  by  the  neat  and 
skilful  it  is  esteemed  of  sufficient  importance  to  de- 
mand as  great  labor  and  pains  as  any  other  part  of 
the  work. 


CHAPTER  VII. 

CLASSIFICATION    OF    DECAYED    CAVITIES. 

The  following  classification  of  decayed  cavities  in 
the  teeth,  though  from  the  very  nature  of  the  subject 
imperfect,  will  be  found  sufficiently  accurate  to  aid 
the  dental  student  and  the  practitioper.  It  is  based 
primarily  on  the  position  of  the  cavities,  and  second- 
arily on  the  extent  of  the  decay, — the  classes  having 
reference  to  the  former  and  the  modifications  to  the 
latter.  The  classes  are  numbered  according  to  the 
accessibility  of  the  cavities,  beginning  with  those  most 
easily  approached  and  operated  upon,  and  the  modifi- 
cations according  to  the  extent  of  the  decay,  begin- 
ning with  the  smallest  and  simplest  in  form. 

First  Class. — Simple  central  crown  cavities  in  the 
molars  and  bicuspids. 

1st  Mod. — Extension  of  the  decay  along  one  or 
more  fissures  or  depressions. 

2d  Mod. — Two  decays  in  close  proximity  on  the 
same  crown,  which  may  be  formed  into  one  cavity  for 
tilling. 

>i  .<  ond  Class. — Cavities  in  the  buccal  and  palatal 
surfaces  of  the  molars  and  bicuspids;  and  in  the  labial 
and  palatal  surfaces  of  the  cuspids  and  incisors. 


218  CLASSIFICATION    OP    DECAYED   CAVITIES. 

1st  Mod. — Extension  of  the  decay  beneath  the 
margin  of  the  gums. 

2d  J  rod. —  Ektension  of  the  decay  so  as  to  involve 
a  portion  of  the  crown  surface. 

Third  Class. — Anterior  proximate  cavities  of  the 
bicuspids  and  molars. 

1st  Mod. — Extension  of  the  decay  toward  the  neck 
of  the  tooth,  beyond  the  termination  of  the  enamel. 

2d  Mod. — Extension  of  decay  so  as  to  involve  a 
portion  of  the  grinding  or  crown  surface. 

Fourth  Class. — Proximate  cavities  of  the  incisors 
and  cuspids. 

1st  Mod. — Palatal  wall  of  the  cavity  broken  away. 

2d  Mod. — Labial  wall  broken  away. 

3cZ  Mod. — The  cavity  at  the  point  of  the  tooth  ter- 
minating at  the  surface. 

4 Hi  Mod. — The  borders  of  the  cavity  very  thin,  and 
the  lateral  w^alls  inclining  to  the  centre. 

Fifth  Class. — Posterior  proximate  cavities  of  the 
molars  and  bicuspids. 

Modifications  same  as  those  of  third  class. 

Modifications  common  to  all  classes  :  1st.  Super- 
ficial cavity  and  a  large  orifice.  2d.  Deep  cavity  and 
a  small  orifice. 

Modifications  common  to  classes  three,  four,  and 
five.  Transverse  extension  of  the  decay  round  one 
or  more  angles  of  the  tooth,  under  the  termination  of 
the  enamel. 


filling  by  (lasses  and  modifications.         219 

Filling  by  Classes  and  Modifications. 

First  Class — Central  cavities  of  the  molars 
and  bicuspids. — These  decays  always  begin  in  the  de- 
pressions on  the  masticatory  surfaces,  which  are  vul- 
nerable [x tints,  the  enamel-membrane  folding  together 
here,  and  often  being  imperfectly  united,  so  that  an 
opening  is  left  partially  or  wholly  through  it  to  the 
dentine  ;  besides,  these  indentations  afford  lodgment 
to  foreign  substances,  which  may  be  forced  into  them 
in  the  process  of  mastication,  and  there  retained  till 
becoming  vitiated,  they  produce  decay. 

Examine  carefully  the  extent  and  the  nature  of 
the  decay,  and  the  form  of  the  cavity,  which,  of 
course,  greatly  varies.  In  some  cases  the  cavity  is 
found  with  a  small  diameter  and  a  comparatively 
great  depth,  the  diameter  at  the  orifice  being  the  same 
as  within  ;  in  others,  with  a  diameter  larger  at  the 
orifice,  as  occurs  in  cases  in  which  a  considerable  por- 
tion of  the  enamel  at  the  depressions  on  the  crown  is 
imperfect.  In  the  majority  of  instances,  however,  the 
diameter  of  the  cavity  is  much  larger  within  than  at 
tin'  orifice.  Sometime-  the  decay  is  found  to  burrow 
directly  beneath  the  enamel  more  rapidly  than  in  any 
other  direction,  as  where  there  is  an  imperfect  union 
between  tic  enamel  and  the  dentine.  In  other  in- 
Btances,  the  cavity  seems  to  expand  uniformly  as  it 
extends  into  the  tooth. 


220  CLASSIFICATION    OF    DECAYED   CAVITIES. 

The  manner  of  opening  and  preparing  the  cavity 
for  filling  will  depend  somewhat  on  the  form  given 
to  it  by  the  decay.  If  it  is  larger  at  the  orifice  than 
within,  there  will  be  little  or  no  cutting  of  the  cav- 
ity about  the  orifice  necessary,  except  to  make  it 
even  and  smooth  ;  and  its  preparation  will  consist  in 
an  entire  removal  of  the  decay,  and  such  shaping 
of  the  interior  as  will  insure  retention  of  the  filling. 
This  may  be  effected  either  by  enlarging  the  cavity 
within,  till  its  walls  are  parallel  with  each  other,  or, 
if  these  are  left  converging,  by  forming  pits  or  grooves 
upon  them  at  proper  points.  Converging  walls  pre- 
sent one  or  two  advantages,  which  will  be  hereafter 
considered.  Usually,  where  the  decay  has  formed  a 
cavity  of  nearly  uniform  diameter  from  the  orifice  to 
the  bottom,  about  all  the  preparation  for  filling  so  far 
as  the  interior  of  the  cavity  is  concerned  that  is 
requisite,  is  a  thorough  removal  of  the  decay.  In  cases 
in  which  the  decay  burrows  under  the  enamel,  the 
projecting  portions  are  to  be  cut  down,  either  with 
a  bur  drill  or,  what  is  generally  better,  a  heavy  cut- 
tins;  instrument.  In  most  instances  it  is  best  to  cut 
away  the  enamel  so  far  as  the  decay  has  extended 
beneath  it,  since  it  is  difficult  to  make  a  perfect  fill- 
ing under  a  projecting  portion.  In  some  cases,  how- 
ever, where  the  enamel  is  thick  and  firm,  it  is  admis- 
sible to  leave  a  slight  projection,  so  as  to  form  a 
shallow  groove. 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  221 

The  walls  of  these  cavities  will  be  of  various  in- 
clinations. If  they  converge,  pits  or  grooves  may  be 
required  upon  them  for  retaining-points,  especially  if 
the  enamel  is  cut  away  at  the  orifice  to  the  solid  den- 
tine. If,  however,  the  walls,  or  two  opposite  walls, 
are  parallel,  or  but  slightly  divergent,  these  special 
retaining-points  will  not  be  requisite,  except  for  the 
reception  of  the  first  pieces  of  gold.  Small  cavities 
of  this  class  may  be  opened  up  and  formed  princi- 
pally with  the  bur  and  drill ;  and  even  in  large  cav- 
ities much  of  the  work  of  opening,  excavating,  and 
forming  may  be  done  with  the  burs  of  the  proper 
size  and  form,  used  with  the  engine.  Thus  the  ori- 
fice of  the  small  cavities  would  be  round,  while  those 
of  the  large  would  be  of  various  forms,  determined  by 
the  direction  of  the  decay,  as  round,  square,  triangu- 
lar, elliptical,  parallelogramic.  Cavities  should  not 
be  formed  much  larger  within  than  at  their  orifices, 
unless  the  filling  can  be  consolidated  so  perfectly 
that  it  will  not  yield  in  the  least  under  the  greatest 
pressure  of  mastication;  for,  if  there  is  yielding  in 
such  cases  under  direct  pressure,  the  filling  being 
forced  into  a  larger  part  of  the  cavity,  withdraws 
from  the  walls,  leaving  an  interval  corresponding 
with  the  degression  it  has  undergone ;  and  thus  fluids 
would  be  admitted  between  the  walls  and  the  filling, 
and  the  purpose  for  which  this  was  inserted  would  be 
entirely  defeated. 


222  CLASSIFICATION    OF    DECAYED   CAVITIES. 

Many  operators  ream  the  orifices  of  all  the  small 
and  medium-sized  cavities  of  this  class,  in  order 
thereby  to  make  a  better  finish  to  the  border  of  the 
filling.  Some  operators  prefer  in  all  eases  to  remove 
the  angle  formed  by  the  wall  of  tin;  cavity  and  the 
surface  of  the  tooth  about  the  orifice,  giving  a  rounded 
form  to  the  border  of  the  orifice,  the  object  being  to 
avoid  fracturing  or  comminuting  the  edge  of  the  en- 
amel or  dentine  about  the  cavity.  All  acute  angles 
in  these  cavities,  especially  if  they  extend  to  the  ori- 
fice, should  be  obliterated,  since  it  is  impossible  to  fill 
them  perfectly.  This  obliteration  can  be  effected  with 
a  miniature  chisel,  or  with  the  appropriate  excavator, 
or,  perhaps,  better  still,  with  the  bur  of  the  proper  size 
and  shape. 

After  the  formation  of  the  cavity,  the  next  particu- 
lar is,  so  to  arrange  as  entirely  to  exclude  moisture, 
whether  from  the  saliva  or  from  the  breath.  If  pro- 
vision was  not  made  at  the  beginning  of  the  operation 
for  the  exclusion  of  moisture,  it  cannot  noAv  be  longer 
delayed.  As  already  intimated  elsewhere,  this  is  ac- 
complished by  the  use  of  the  rubber  dam.  The  gen- 
eral method  of  its  application  has  been  considered,  yet 
a  few  suggestions  in  reference  to  it  in  an  operation 
upon  this  class  of  cavities  may  be  of  value,  especially 
to  the  beginner. 

The  precise  method  of  procedure  at  this  point  will 
be  modified  by  the  size  of  the  mouth  and  the  ability 


FILLING    BY    CLASSES    AXD    MODIFICATIONS.  223 

or  will  of  the  patient  to  control  it.  For  a  cavity  of 
this  class,  it  will,  in  nearly  all  cases,  where  the  month 
is  favorable  in  the  particulars  just  referred  to,  be  quite 
sufficient  to  embrace  with  the  rubber  only  the  tooth  to 
be  operated  upon,  and  this  whether  it  be  in  the  supe- 
rior or  inferior  jaw. 

If  the  tooth  in  question  stands  in  firm  contact  with 
its  neighbors,  passing  the  rubber  between  the  teeth  may 
be  quite  unnecessary,  but  let  it  be  drawn  over  the  crown 
and  down  or  up,  as  the  case  may  be,  upon  the  buccal 
and  lingual  sides  to  the  margin  of  the  gum,  then 
place  on  the  clamp,  which  will  hold  all  in  position. 

This  properly  done,  all  moisture  will  be  effectually 
excluded;  success  in  this,  however,  depends  somewhat 
on  the  accurate  adaptation  of  the  clamp  to  the  tooth. 
If  the  rubber  can  be  readily  passed  between  this  and 
either  or  both  of  the  contiguous  teeth,  it  is  well  to  do 
so,  thus  making  the  work  more  secure,  if  the  clamp 
should  be  defective  in  adaptation.  When  the  mouth 
is  -mall,  or  not  properly  controlled,  greater  precaution 
will  be  requisite;  in  such  cases  the  rubber  should 
always  be  passed  between  the  teeth,  and  in  some  in- 
stances* over  one  or  two  neighboring  teeth,  in  order 
that  the  operation  may  not  be  embarrassed  by  en- 
croachment of  the,  rubber.  But  in  no  case  should  it 
be  placed  upon  more  teeth  than  are  necessary  to  meet 
the  demands  of  the  case.  The  free  border  of  the 
robber  should  now  have  the  elastic  bands  applied,  so 


22  i  CLASSIFICATION    OF    DECAYED    CAVITIES. 

thai   the  utmost  freedom  of  approach   may  be  made 

to  the  point  of  operation.  The  cavity  should  he 
thoroughly  dried  with  bibulous  paper  and  the  warm- 
air  blowpipe;  when  a  minute  examination  of  the 
cavity,  at  every  point  and  in  every  particular,  should 
be  made,  and  any  imperfections  remedied.  And 
now,  with  the  automatic  saliva  extractor  in  place 
and  operating,  the  work  of  introducing  the  filling  may 
proceed. 

In  some  small  simple  cavities  of  this  class,  in  the 
upper  teeth,  with  conditions  favorable,  and  but  a  short 
time  required  for  introducing  the  filling,  the  following 
arrangement  may  serve  the  purpose :  Wipe  dry  the 
mucous  membrane  about  the  mouth  of  the  duct  of 
Steno,  lay  directly  upon  this  a  piece  of  heavy  blot- 
ting-jmper,  or  a  roll  of  bibulous  paper;  then  take  a 
napkin  folded  cornerwise,  place  the  end  of  it  upon 
the  paper  between  the  cheek  and  the  gum,  passing  it 
back  of  the  tooth  to  be  operated  upon  along  the  pal- 
atal surfaces  of  the  teeth  and  the  gums  to  the  anterior 
part  of  the  mouth,  and  letting  a  fold  of  it  extend 
down  from  this  and  out  over  the  inferior  front  teeth 
and  the  lip,  so  as  to  protect  the  tooth  from  the  breath, 
and  catch  any  fragments  of  gold  that  may  drop  from 
the  instrument.  The  napkin  and  paper,  thus  ar- 
ranged, are  to  be  kept  in  their  place  by  the  fingers 
of  the  left  hand  of  the  operator,  and  if  the  mouth  of 
the  duct  is  kept  closed  by  the  jjaper  a  complete  ex- 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  225 

elusion  of  moisture  is  secured,  so  far  as  that  source 
is  concerned.  In  some  cases,  pressure  of  the  fingers 
on  the  napkin  over  the  duct  is  necessary,  in  others 
the  paper  adheres  to  the  mucous  membrane  and  effec- 
tually prevents  the  egress  of  saliva.  The  cavity  should 
now  be  dried  by  the  method  heretofore  described,  and 
it  is  ready  for  the  filling. 

In  the  absence  of  the  automatic  saliva   extractor, 
the  saliva  pump,  represented  in  Fig.  88,  will  serve  a 


Fig. 


valuable  purpose,  though  it  does  not  completely  fulfil 
the  requirements. 

An  instrument  invented  by  Dr.  W.  H.  Dibble, 
called  "  Dibble's  Saliva  Pump,"  performs  the  work  of 
both  the  saliva  pump  and  tongue-holder.  As  a  saliva 
pump  it  is  much  superior  to  the  instrument  represented 
in  Fig.  88,  which  is  in  common  use. 

It  is  operated  by  the  patient,  and  removes  the  saliva 
immediately  after  it  enters  the  mouth,  and  may  be  in 
constant  action  without  the  slightest  interruption  of 
the  operation  of  filling;  the  saliva  passes  into  a  res- 
ervoirand  is  perfectly  inclosed  till  the  operation,  how- 
ever protracted,  is  completed. 


226  classification  of  decayed  cavities 

1  i...    89. 


Thai  pari  of  the  instru- 
ment designed  to  1 1< *1  < I  the 
tongue  and  the  buccal  sur- 
face from  ilif  tooth  to  be 
operated  upon,  and  to  hold 
the  jaws  apart,  is  of  a  very 
excellent  form,  and  ac- 
complishes its  work  well. 
It  is  in  three  parts,  one 
adapted  to  each  side  of  the 
mouth — in  these  thesaliva 
is  taken  up  by  the  instru- 
ment opposite  the  lingual 
surface  of  the  second  in- 
ferior molar — and  one  for 
the  front,  with  a  compres- 
sor passing  on  to  the 
tongue. and  holdingil  firm- 
ly down,  and  the  pump- 
tube  takes  the  saliva  from 
the  immediate  vicinity  of 
the  sublingual  ducts. 

This  latter  part  of  the 
instrument  is  the  device  of 
Dr.  1>.  F.  Arrington.  The 
instrument  is  well  repre- 
sented in  Fig.  89.  That 
part  of  this  instrument  de- 
signed to   hold   down  the 


FILLING    BY   CLASSES   AND   MODIFICATIONS.  227 

tongue  is  rendered  unnecessary  by  the  use  of  the  rub- 
ber dam. 

It  is  often  the  case  that  the  finger  is  too  short  to 
reach  a  desired  point  to  hold  down  a  napkin  or  paper, 
or  hold  away  the  soft  parts,  or  is  so  large  as  to  fill 
the  space  inconveniently,  obstructing  the  view  of  the 
operation.     To  overcome  both  of  these  difficulties  an 

Fig.  90. 


extension  thimble  is  used  ;  it  may  be  made  of  silver 
or  rubber,  though  better  of  the  former.  In  addition  to 
the  uses  mentioned,  it  may,  by  having  a  fine  steel 
point,  be  made  to  serve  as  a  holder  to  aid  in  introduc- 
ing fillings.     (Fig.  90.) 

Filling  with  Foil. — If  non-cohesive  gold  is  employed 
it  should  be  formed  into  blocks,  by  cutting  from  four  to 
eight  thicknesses  into  strips  one  fourth  wider  than  the 
cavity  is  deep,  and  rolling  them  on  a  broach,  suitable 
for  the  purpose,  into  cylindrical  blocks  corresponding 
in  -i/.<-  with  the  cavity  to  be  filled,  and  varying  not 
only  in  size,  but  in  form  and  density.  The  blocks 
firsl  to  be  introduced  should  be  largest,  followed  by 


228  CLASSIFICATION   OF   DECAYED   CAVITIES. 

those  diminishing  in  size,  the  last  portions  being  small, 
dense,  conical  rolls.  Where  there  is  an  inward  or 
outward  inclination  of  the  walls  of  the  cavity,  the  first 
blocks  should  be  cone-shaped.  For  introducing  the 
blocks,  the  plugging  pliers  will  be  required.  The  first 
block  is  taken  up  with  this  instrument  and  placed 
against  the  posterior  wall  of  the  cavity,  with  one  end 
on  the  bottom  and  the  other  protruding  from  the  orifice, 
and  there  compressed  firmly  to  its  place  with  the  ap- 
propriate condensing  instrument ;  and,  unless  there  is 
some  special  retaining  space,  it  may  be  necessary  to 
hold  it  in  its  position  with  a  second  instrument,  till 
the  next  portion  is  added.  As  the  successive  blocks 
are  introduced,  each  is  to  be  thoroughly  consolidated, 
so  as  to  be  immovable.  The  filling  is  to  proceed  from 
the  posterior  wall  to  the  centre.  After  the  cavity  has 
thus  been  filled  to  the  centre,  commence  in  the  same 
manner  at  the  anterior  wall,  filling  from  thence  toward 
the  centre,  and  condensing  the  last  blocks  by  forcing 
in  at  their  side  a  small  sharp-pointed  instrument ;  the 
final  portion  introduced  will  be  the  small,  dense,  con- 
ical roll  already  mentioned.  The  gold  being  all  intro- 
duced, a  smooth-pointed  instrument  or  burnisher  con- 
denses the  projecting  portion  of  the  filling  till  it  is 
perfectly  solid,  when  it  is  finished  with  a  file,  stone 
and  burnisher  in  the  manner  already  described.  The 
particular  shape  of  the  surface  of  the  filling  will  be 
suggested  by  the  form  of  the  antagonizing  tooth.    Usu- 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  229 

ally  the  surface  of  these  fillings  should  be  slightly 
concave ;  in  some  cases  the  occlusion  of  the  teeth  is 
such  as  to  require  very  considerable  concavity ;  this, 
however,  should  only  be  sufficient  to  accommodate  the 
closure  of  the  teeth. 

For  dressing  down,  the  burs,  corundum  cones,  Scotch 
stone  and  buff  cones  used  with  the  engine,  represented 
by  Figs.  28  and  29,  will  serve  the  purpose  most  fully. 

Cohesive  Foil. — For  filling  these  cavities  with  cohe- 
sive foil,  definite  retaining-points  should  be  formed  in 
them,  or  the  bottom  of  the  cavity,  of  such  a  form  as  to 
retain  firmly  in  position  the  first  pieces  of  gold  intro- 
duced. The  gold,  prepared  in  the  manner  already 
described,  is  taken  up  with  a  serrate-pointed  plugger 
or  plugging  pliers,  introduced  into  the  retaining-point 
or  points,  and  there  fixed  ;  it  is  then  built  across  from 
one  to  the  other,  and  over  the  floor  of  the  cavity  till 
this  is  completely  covered,  and  then  up  from  the  bottom 
to  the  orifice.  When  a  portion  of  gold  is  taken  on  the 
point  of  the  instrument,  the  precise  spot  at  which  to 
deposit  it  should  be  selected,  and  there  it  should  be 
placed,  and,  by  the  first  pressure  of  the  instrument, 
fixed  immovably  ;  a  few  subsequent  strokes  of  the  in- 
strument, near  the  first  point  of  attachment,  will  be 
required.  These  strokes  should  be  close,  because  if 
the  instrument  is  lifted  up  and  pressed  upon  the  piece 
at  a  distance  from  the  first  point  of  contact,  the  attach- 
ment i-  liable  to  be  broken.    The  character  of  the  gold, 


230  CLASSIFICATION    OF    DECAYED    CAVITIES. 

and  the  condition  of  the  receiving  surface  will  govern 
to  some  extent  the  precise  method  of  manipulation. 
Very  much  depends  upon  keeping  the  surface  in  a 
good  condition  for  the  reception  of  the  gold  to  be  added. 
The  besl  receiving  surface  is  obtained  by  having  the 
condensing  instrument  sharp  and  in  good  condition, 
and  then  in  using  it,  lei  there  bea  little  space  between 
its  impressions — the  surface  nol  stamped  completely 
over  by  the  condensing  instrument.  Ln  constructing 
the  filling,  we  consider  it  preferable  to  keep  it  built  up 
a  little  higher  all  around  next  the  walls  than  at  the 
centre,  for  the  reason  that  a  more  complete  adaptation 
of  the  gold  can  thus  be  made  than  by  any  other  plan. 
Some,  however,  advocate  the  opposite  practice;  that 
is,  of  keeping  the  filling  higher  in  the  centre  than  al 
the  walls,  and  thus  forming  an  angular  space  into 
which  to  crowd  the  gold  ;  because  the  gold  is  thus  kept 
in  more  thorough  contact  with  the  walls  of  the  cavity ; 
and  it  is  objected  that,  to  add  and  consolidate  the  gold 
to  the  centre,  while  the  edges  are  left  higher,  tends 
to  draw  them  from  the  walls.  This  objection,  however, 
has  no  force,  if  the  gold  is  thoroughly  consolidated  as 
it  is  introduced. 

The  cavity  is  thus  tilled  up,  consolidated,  and  fin- 
ished in  the  usual  manner.  In  adding  the  lasl  por- 
tions of  gold,  great  care  should  be  taken  to  make  a 
perfect  border  to  the  filling.  Crystal  gold  may  be  very 
advantageously  used  as  a  foundation   for  cohesive  foil 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  231 

fillings,  as  it  will  retain  its  position  perfectly  in  a  cav- 
ity, where  foil  will  not. 

Crystal  Gold. — The  method  of  filling  this  class  of 
cavities  with  crystal  gold  is  very  simple.  The  mate- 
rial should  be  annealed  just  before  its  use,  and  then 
cut  or  broken  into  blocks  corresponding  with  the  size 
of  the  cavity  to  be  filled  ;  they  may  be  used  as  large 
as  will  freely  enter  the  cavity  ;  many  small  pieces 
will  be  required  to  fill  up  interstices  or  angles.  The 
filling  may  be  commenced  at  the  bottom  of  the  cavity, 
and  built  up  from  that  to  the  orifice,  the  same  plan 
being  followed  in  adapting  it  to  the  walls  as  with  co- 
hesive foil,  the  pieces  being  passed  into  the  cavity 
with  either  the  plugging  pliers  or  a  condensing  in- 
strument. Each  piece  should  be  well  consolidated 
before  another  is  added.  For  condensing  the  filling 
next  to  the  walls,  a  small  wedge-shaped  instrument  is 
valuable.  In  all  cases  where  there  is  a  divergence  of 
the  anterior  wall,  care  is  required  to  make  an  efficient 
filling;  and  too  much  care  cannot  be  exercised  in  per- 
fecting the  filling  round  the  border  of  the  cavity. 
In  condensing  cohesive  foil  or  crystal  gold,  the  force 
may  be  applied  as  nearly  as  practicable  in  a  line  with 
the  axis  of  the  tooth  ;  this  is  always  preferable  to 
lateral  pressure. 

1.7  Mod. — Extension  of  decay  along  one  or  more 
of  the  crown  fissures. —  In  a  case  of  this  kind,  the 
centra]    cavity   is    first    to    he   opened   and    excavated, 


232  CLASSIFICATION   OF    DECAYED    CAVITIES. 

according  to  the  principles  already  announced.  Decay 
in  the  fissures  is  in  some  cases  an  extension  of  the 
central  decay,  and  at  the  point  of  its  termination 
there  will  be  found  an  acute  angle ;  but  in  others,  it 
will  be  the  effect  of  an  equal  attack  all  along  the 
fissure,  or  of  an  extension  from  some  other  point 
than  the  central  cavity.  This  modification  of  decay 
may  terminate  either  in  an  acute  angle  or  in  an  ex- 
pansion. 

These  decayed  fissures  should  be  opened  up  by  cut- 
ting away  any  projecting  portion  of  enamel,  and  the 
cavities  formed  with  a  small  chisel-shaped  instrument, 
beginning  at  the  juncture  of  the  fissure  with  the  main 
cavity,  and  cutting  down  to  the  bottom  of  the  decay 
in  the  manner  of  a  mortise,  thus  cutting  out  the  en- 
tire fissure  and  the  acute  angle  at  its  termination — 
the  latter  is  an  important  consideration.  In  case 
there  is  a  very  considerable  expansion  of  decay  at 
the  termination  of  the  fissure,  the  bur  drill  may  be 
introduced  into  it,  and  the  rest  of  the  fissure  cut  out, 
as  the  form  of  the  cavity  may  indicate.  In  exca- 
vating and  forming  these  fissures,  the  burs  made  for 
the  purpose  (shown  in  Fig.  22),  and  used  with  the 
engine,  give  greater  facility  and  rapidity  of  execution 
than  by  the  method  just  described,  and  with  care, 
equally  as  definite  results. 

If  blocks  are  used  to  fill  these  cavities,  they  should 
be  set  in  and  compressed  against  the  end  of  the  fis- 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  233 

sure,  protruding  from  it  sufficiently  to  admit  of  a 
proper  finish ;  and  block  after  block  added,  till  the 
fissure  is  filled  to  the  main  cavity.  Where  there 
are  two  or  three  of  these  decayed  fissures  in  one 
tooth,  it  may  be  quite  as  much  as  can  be  done  at 
one  sitting  to  fill  them,  the  main  cavity  being  left 
for  another  time.  In  such  cases,  the  filling  introduced 
at  the  first  sitting  should  then  be  consolidated  and 
burnished,  so  that  it  may  not  absorb  moisture  while 
the  main  cavity  is  filled,  as  already  described.  Much 
care  should  be  exercised  to  prevent  the  gold  from 
overlapping  the  enamel  at  the  sides  of  these  fissures. 
In  filling  this  modification  with  crystal  gold  or  an- 
nealed foil,  it  is  better  to  begin  at  the  bottom  of  the 
cavity  and  build  up  to  the  orifice,  first  completing 
the  fissure,  as  we  have  already  described,  and  after- 
ward the  main  cavity. 

2d  Mod. —  Tivo  cavities  on  the  same  crown  in  close 
proximity. — The  thickness  of  the  portion  of  tooth  in- 
tervening between  two  cavities  on  the  grinding  sur- 
face of  the  same  crown  is  determined  by  the  location 
and  extent  of  the  decay  and  by  the  form  of  the 
cavities;  and  these  two  conditions  will  suggest  the 
method  of  operation.  If  this  intervening,  portion  is 
thin  throughout,  and  devoid  of  vitality,  it  should  be 
cut  away,  and  the  two  cavities  formed  into  one ;  but 
if  it  Ls  thick  within,  though  it  may  be  thin  at  the 
surface,  the  cavities  should  be  filled  separately.     In 


234  CLASSIFICATION   OF    DECAYED   CAVITIES. 

some  cases  it  is  proper  to  leave  a  part  of  it  standing, 
as  a  sort  of  ridge  between  the  cavities,  though  not  as 
a  definite  partition  ;  in  which  case  the  filling  would  be 
commenced  as  in  two  cavities,  and  finished  as  in  one. 
In  no  case,  however,  when  the  tooth  is  living,  should 
this  intervening  portion  remain,  if  its  vitality  is  gone. 
The  details  of  the  process  of  filling  crown  cavities 
have  already  been  indicated. 

Second  Class. — Buccal  and  palatal  cavities  of 
the  molars  and  bicuspids,  and  labial  and  palatal 

CAVITIES  OF  THE   CUSPIDS  AND   INCISORS. In  the   DIO- 

lars,  this  class  of  decay  begins  either  at  the  margin  of 
the  gum,  in  the  form  of  a  transverse  groove,  or  along 
the  vertical  depression  on  the  buccal  surface  of  the 
tooth,  or  at  its  termination.  These  groove-like  decays, 
extending  along  the  side  of  the  tooth  at  or  near  the 
margin  of  the  gum,  are  ordinarily  not  very  deep ;  but 
they  burrow  considerably  under  the  enamel,  particu- 
larly at  the  side  next  the  grinding  surface.  In  prepar- 
ing these  cavities,  the  projecting  portion  of  the  enamel 
must  be  mostly  cut  away,  leaving  them  but  slightly 
larger  within  than  at  the  orifice.  These  grooves,  at 
their  ends,  are  shallow  ;  but  in  their  preparation  for 
filling,  they  should  be  cut  as  deep  at  the  ends  as  else- 
where, and  deeper,  when  the  main  part  of  the  cavity 
is  comparatively  shallow.  Much  difficulty  is  often 
experienced  in  protecting  these  cavities  from  moisture 
while  being  filled.     The  rubber  dam,  when  well  ap- 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  235 

plied,  accomplishes  the  object  better  than  any  other 
appliance;  it  is  in  such  cases  invaluable. 

The  method  of  introducing  gold  in  the  form  of 
blocks  into  these  cavities,  is  to  set  in  the  first  block  at 
the  posterior  part  of  the  cavity,  and  consolidate  it,  and 
so  one  block  after  another  till  the  cavity  is  nearly  full ; 
and  then  proceed  in  like  manner  with  the  anterior  end, 
back  toward  the  middle,  the  blocks,  of  course,  being 
permitted  to  protrude  sufficiently  for  the  purposes  of  a 
finish.  For  filling  with  crystal  gold  or  cohesive  foil, 
the  method  is,  to  form  pits  at  the  end  of  the  groove, 
into  which  the  gold  is  consolidated,  and  built  across 
from  one  to  the  other,  and  then  up  from  the  bottom  to 
the  orifice,  when  it  is  finished  as  usual.  Care  is  re- 
cpiisite  to  prevent  the  gold  from  overlapping  the  tooth 
outside  of  the  cavity.  Any  projection  of  the  filling, 
especially  beyond  the  margin  of  the  cervical  wall  of 
the  cavity,  is  very  objectionable  ;  it  would  afford  a 
lodgment  for  extraneous  substances,  the  tendency  of 
which  is  to  produce  irritation  and  decay. 

Cavities  of  this  class,  which  are  formed  in  the  de- 
pressions of  the  buccal  portions  of  the  teeth,  are  more 
easily  filled.  Often  a  simple  round  cavity  is  formed 
at  the  coronal  termination  of  this  depression,  which 
may  be  entirely  prepared  with  a  bur  drill.  The 
method  of  filling  these  cavities  will  be  readily  inferred 
from  the  remarks  before  made.  If,  however,  the  decay 
extends  along  the  depressions,  making  a  groove-like 


236  CLASSIFICATION   OF   DECAYED   CAVITIES. 

cavity,  tin's  should  be  filled  by  commencing  the  intro- 
duction of  the  gold  at  that  part  of  the  cavity  next  the 
gum. 

1st  Mod. — Decay  at  or  near  the  neck  of  the  tooth, 
and  partially  or  wholly  overlapped  by  the  free  border 
of  the  gum. — In  this  modification  the  gum  is  an  ob- 
stacle  to  the  various  steps  in  the  process  of  filling.  It 
is  liable  to  be  wounded  and  to  bleed  at  every  touch  ; 
it  exudes  mucus  constantly  ;  and  it  conducts  saliva  to 
the  part  with  great  facility.  To  obviate  these  difficul- 
ties, the  gum  must  be  removed  somewhat  from  the 
cavity  before  the  filling  is  practicable.  This  removal 
of  the  free  margin  of  the  gum  may  be  made  either  by 
cutting  away,  or  by  pressing  away  with  pledgets  of 
cotton  or  other  appropriate  substance  placed  in  the 
cavity  and  projecting  from  it,  so  as  to  make  pressure 
upon  and  absorption  of,  to  a  sufficient  extent,  the  free 
margin  of  the  gum,  which  will  usually  be  accomplished 
in  a  day  or  two.  The  former  method,  however,  accom- 
plishes the  object  at  once :  some  good  hemostatic,  as 
creasote  and  tannin,  or  better,  persulphate  of  iron,  is 
all  that  is  then  necessary  to  render  the  filling  imme- 
diately practicable.  By  means  of  this  application  the 
exudation  is  checked, — which,  where  there  is  much 
mucus  eliminated,  is  an.important  item, — and  also  such 
a  surface  is  given  to  the  part  that  it  will  not  so  readily 
conduct  the  saliva.  It  is  perhaps  preferable  in  many 
cases  to  cut  away  this  free  margin,  so  that  it  shall  not 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  237 

be  in  contact  with  the  filling  after  the  operation  is 
completed.  In  nearly  all  such  cases,  by  the  proper 
application  of  the  rubber  dam  with  a  perfectly  adapted 
clamp,  the  whole  difficulty  will  be  overcome. 

After  this  preparation,  the  cavity  is  formed  and 
filled  as  usual. 

In  filling  cavities  of  the  buccal  portions  of  the  third 
molars,  peculiar  difficulties  are  encountered.  The  de- 
cay is  frequently  found  two-thirds  covered  by  the  gum  ; 
the  muscles  of  the  cheek,  thick  and  rigid,  lie  close 
against  the  side  of  the  tooth  ;  and,  in  most  cases  of  this 
kind,  the  view,  at  best,  is  but  partial.  To  meet  this 
difficulty,  a  clamp  with  a  broad  flange  upon  its  outer 
blade  is  required  for  holding  the  soft  parts  away,  and 
the  rubber  dam  in  its  proper  position. 

In  nearly  all  such  cases  the  reflector  should  be  used 
to  concentrate  light  upon  the  locality  of  the  operation ; 
without  this,  the  view  into  these  cavities  is  much  ob- 
scured. 

Third  Class. — Anterior  proximate  cavities  of 
the  molars  and  bicuspids. — This  class  of  cavities  in 
teeth  with  short,  broad  crowns,  takes  place  at  their 
necks;  but  in  those  with  long  crowTns,  and  with  a  diam- 
eter less  at  the  neck  than  at  the  masticating  surface,  it 
begins  at  some  distance  from  the  neck,  toward  the  crown 
surface,  or  at  the  first  point  of  contact  of  the  crowns. 
In  almosl  all  cases  of  proximate  fillings  separation  of 
the  teeth  is  required;  the  method  and  extent  of  this 


238  CLASSIFICATION'   OF   DECAYED   CAVITIES. 

will  be  determined  by  circumstances.  If  all  the  neigh- 
boring teeth  stand  in  contact,  it  cannot  be  easily  ac- 
complished by  pressure  ;  in  this  respect,  however,  there 
will  be  found  a  great  variety ;  but  if  a  tooth  has  been 
extracted  in  the  vicinity,  or  there  are  natural  spaces 
between  the  others,  it  can  be,  either  in  whole  or  in  part. 
When,  however,  the  teeth  stand  close  together,  they 
must  in  such  case  be  separated  chiefly  with  the  chisel 
and  file.  If  but  one  is  decayed,  the  cutting  should  be 
exclusively  from  that.  If  two  are  alike  affected  on 
their  proximate  surfaces,  it  should  be  mostly  from  the 
posterior  surface  of  the  anterior  tooth.  In  regard  to 
the  form  of  the  separation  effected  by  cutting,  the  gen- 
eral practice  formerly  was  to  cut  down  the  whole  prox- 
imate side  of  the  affected  tooth,  making  between  it  and 
the  adjoining  one  a  V-shaped  space,  sufficient  in  extent 
to  admit  of  free  manipulation  in  all  parts  of  the  opera- 
tion of  filling.  By  thus  cutting  the  teeth,  the  form  is 
marred,  and  often  to  great  disadvantage  in  use,  as  by 
it  the  masticating  surface  is  lessened,  and  food  being 
crowded  into  such  a  space,  produces  very  unpleasant 
pressure.  In  order  to  preserve  the  form  and  the 
greatest  amount  of  masticating  surface  to  the  tooth,  a 
preferable  method  is  to  cut  down  from  the  masticating 
surface  to  the  cavity  of  decay,  leaving  the  lingual  and 
buccal  sides  of  the  tooth  untouched,  except,  perhaps,  a 
little  dressing  that  may  be  rendered  necessary  by  the 
thinness  and  roughness  of  the  margins.     This  cutting 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  239 

should  extend  about  as  far  toward  the  centre  of  the 
tooth  as  the  decay  has  penetrated,  and  be  nearly  as 
wide  as  the  extent  of  the  decay  across  the  tooth  ;  it 
should  be  of  dovetail  form,  or  that  part  of  the  opening 
next  to  the  centre  of  the  crown  slightly  wider  than  at 
the  anterior  part.  This  form  may  very  readily  be 
given  by  the  properly-formed  excavators,  or  more  rap- 
idly, and  quite  as  well,  with  the  fissure  burs  and  engine. 
Care  should  be  exercised  in  this  particular,  lest  the 
lateral  walls  of  the  cavity  be  weakened  by  this  cutting ; 
and  in  doubtful  cases,  rather  than  incur  such  risk,  it 
is  better  to  avoid  making  the  expansion  altogether, 
and  rely  upon  other  modes  of  anchorage  for  the  filling. 
The  attachment  of  the  filling  may  be  made  by  prop- 
erly located  pits  and  grooves.  In  making  these,  two 
points  should  be  guarded,  viz.,  weakening  the  walls 
of  the  cavity,  and  impingement  upon  the  pulp.  Care, 
good  judgment  and  experience  are  necessary  to  most 
fully  meet  these  requirements.  When  it  is  necessary 
to  cut  from  the  whole  proximate  surface,  there  should 
be  no  shoulder  or  projection  feft  at  the  neck  of  the 
tooth,  but  the  cut  surface  should  be  plain  from  the 
crown  to  its  termination  at  or  near  the  neck.  The 
space,  of  whatever  form  it  may  be,  should  be  large 
enough  to  enable  the  operator  to  manipulate  with  facil- 
ity, and  to  see  as  directly  as  possible  into  the  cavity. 

Cavities  of  this  class  are  various  in  form;  and  they 
require  much  -kill  in  their  excavation  and  formation. 


240  CLASSIFICATION    OF    DECAYED    CAVITIES. 

Special  care  is  to  be  exercised  not  to  leave  any  portion 
of  decay  in  them.  By  a  fatal  oversight,  decayed  den- 
tine is  often  permitted  to  remain  on  thai  side  nexl  to 
the  neck  ofthe  tooth  :  and  fillings  thai  in  other  respects 
are  good,  are  very  deficient  here — so  deficient,  indeed, 
thai  a  sharp  instrument  will  readily  penetrate  the  soft- 
ened dentine  above  them,  or  even  pass  between  the 
filling  and  the  wall  of  the  cavity.  The  removal  of  the 
decay  from  the  cervical  walls  of  all  proximate  cavities 
is  an  important  particular,  neglect  of  which  occasions 
many  failures.  This  class  of  cavities  at  this  point 
should  be  most  thoroughly  filled  ;  for  it  is  more  vul- 
nerable than  any  other,  on  account  of  the  facility  with 
which  foreign  substances  are  here  lodged  and  retained. 

In  the  formation  of  these  cavities,  the  cervical  wail 
should  be  made  to  incline  slightly  outward,  and  the 
lateral  walls,  if  the  tooth  will  bear  the  loss,  made  at 
least  parallel  with  each  other;  but  if  that  would  im- 
pair its  strength,  grooves  or  pits  may  be  made  upon 
them  for  this  purpose  at  proper  points.  When  these 
cavities  are  large,  the  dentine  is  usually  all  decayed 
in  that  part  of  the  cavity  next  to  the  masticating 
surface  of  the  tooth,  leaving  only  the  enamel,  which 
by  the  mode  of  separating  or  opening,  already  de- 
scribed, would  be  cut  away. 

The  rubber  dam  being  properly  adjusted,  the  cavity 
is  ready  for  the  filling:,  which  is  introduced,  if  in 
blocks,  as  before   detailed,  beginning  with  the  cervi- 


FILLING   BY    CLASSES    AND    MODIFICATIONS.  241 

cal  wall.  The  caution  may  here  again  be  urged,  not 
to  let  the  gold  to  overlap  the  tooth,  particularly  at  the 
cervical  wall.  In  filling  with  crystal  gold  or  cohe- 
sive foil,  special  retaining  spaces  will  be  required  in 
this  wall,  two  being  generally  sufficient,  one  toward 
the  outer  and  the  other  toward  the  inner  lateral  wall, 
on  both  of  which  grooves  may  be  made,  if  the  walls 
are  thick  enough  to  admit  of  it.  If,  however,  these 
walls  are  not  parallel,  and  will  not  admit  of  grooves, 
the  crown  and  the  cervical  walls  should  be  so  shaped 
as  to  retain  the  filling.  But  in  some  cases  the  at- 
tachment of  the  filling  is  made  entirely  at  the  cer- 
vical wall ;  and  best  by  means  of  three  pits,  made 
with  the  square-pointed  drill  at  different  angles,  and 
in  such  directions  as  not  to  interfere  with  the  pulp. 
This  kind  of  attachment  will  serve  only  for  cohesive 
gold,  which  is  to  be  very  thoroughly  consolidated 
into  the  pits,  making  little  projections,  which  are  so 
many  anchors  for  fastening  the  filling,  and  built  very 
firmly  across  from  one  to  the  other. 

"2d  Mod. — Decay  involving  a  portion  of  the  masti- 
cating  surface. — There  are  two  methods  of  filling  this 
modification.  One  is,  to  cut  down  the  tooth  or  the 
projecting  angles,  and  make  a  plain,  oblique  border 
to  the  cavity  by  the  V-shaped  separation  already  re- 
ferred to,  and  then  filled  up  flush  with  this  border. 
The  filling  will  thus  exhibit  a  single,  uniform  surface, 
;tt  a  considerable  angle  with  the  axis  of  the  tooth. 

16 


242  CLASSIFICATION    OF    DECAYED    CAVITIES. 

\\  lien  a  portion  of  the  crown  breaks  down  in  eon- 
sequence  of  proximate  decay,  ii  is  toward  the  centre 
of  the  tooth  ;  usually  the  inner  and  outer  corners  re- 
main. If  these  projections  are  feeble  and  liable  to 
be  broken  away,  they  should  be  cut  down  and  the 
cavity  filled  as  before  described.  It",  however,  they 
are  linn,  they  should  remain,  ami  the  cavity,  prop- 
erly formed,  may  be  filled  so  as  to  restore  the  tooth's 
original  Conn,  which  in  the  molars  and  bicuspids 
should  he  accomplished  as  nearly  as  possible,  in  order 
that  the  function  of  mastication  should  be  perfectly 
preserved.  My  properly  directed  effort,  the  crowns 
of  the  teeth  can  in  almost  all  cases,  even  where  the 
walls  are  broken  away,  be  well  restored.  Non-cohe- 
sive foil  is  not  adaptable  to  this  kind  of  filling,  a-  it 
cannot  be  built  in  so  as  to  withstand  the  pressure  of 
mastication.  In  no  case  should  a  proximate  Idling  be 
left  in  contact  with  the  adjoining  tooth;  with  another 
filling  it  may. 

Fourth  Class. — Proximate  cavities  of  the  in- 
cisors and  cospidati. — If  the  teeth  are  not  in  a 
crowded  condition,  and  the  file  is  not  requited  by  the 
extent  of  the  decay,  separation  may  he  made  by  pres- 
sure; but  if  the  cavity  is  Large,  and  the  walls  are  thin 
and  friable,  cut  with  a  thin  chisel,  or  better  with  the 
diamond  disk,  till  a  good  border  is  obtained  about  the 
cavity.  Much  has  been  said  as  to  the  form  of  these 
separations,  some  recommend  that  they  be  larger  at  the 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  243 

palatine  part  than  at  the  labial ;  others,  that  they  be 
larger  at  the  points  than  at  the  necks  of  the  teeth  ; 
some,  that  a  shoulder  be  left  at  the  necks ;  and  others, 
that  there  be  no  shoulder  at  all.  In  making  these 
separations,  however,  the  operator  must  be  governed 
somewhat  by  circumstances,  no  general  rule  being  ap- 
plicable to  all  cases.  The  form  of  the  teeth  and  the 
extent  of  the  decay,  together  with  the  character  of 
the  remaining  enamel  and  dentine,  will  modify  the 
form  of  the  space  between  them.  If  the  inner  wall 
is  thin  or  broken  away, — and  it  is  usually  more  fria- 
ble and  more  broken  than  the  labial  wall, — it  should 
be  cut  off  more  than  the  outer  ;  in  which  case  the  pal- 
atine aspect  of  the  separations  will  be  the  largest — as, 
indeed,  some  prefer  to  make  it  in  all  cases,  perform- 
ing the  remainder  of  the  operation  from  the  inside. 
Almost  every  operation  upon  these  teeth  will  require 
attention  and  manipulation,  in  every  step,  from  both 
the  palatal  and  labial  sides,  in  order  to  make  secure 
every  point.  The  precise  mode  of  procedure  must  be 
determined  by  the  case  to  which  it  is  to  be  applied. 
The  most  direct  approach  is  always  to  be  employed 
when  practicable. 

In  some  cases  separation  will  be  larger  at  the  points 
of  the  teeth  than  elsewhere  ;  as,  where  there  has  been 
a  partial  fracture  at  the  points.  In  cutting  away  to 
make  tin  separation,  no  shoulder  should  be  left  at  the 
neck  of  the  tooth  that  is  not  to  be  protected  by  fill- 


•J  M  'I    \->  I  IK  AII<  '  N    OF    DECAYED    CAVITIES. 

ing;  ;in\'  projection  of  thai  kind  is  always  objection- 
able: foreign  substances  lodge  upon  and  adbere  to  it, 
and,  becoming  vitiated,  render  ii  very  liable  to  decay. 
Thecutting  should  always  extend  entirely  beyond  the 
decay,  but  only  Par  enough  to  make  a  perfectly  plain 
border  to  all  the  cavity,  and  should  terminate  withoul 
any  projection.  It  is  highly  important,  in  separating 
the  anterior  teeth  to  make  as  little  alteration  a-  pos- 
sible in  their  form.  Bui  the  preservation  of  the  tooth 
should  nut  be  jeopardized  for  the  sake  of  maintaining 
wholly  its  natural  form.  The  first  consideration 
should  be  to  obtain  a  space  sufficient  for  the  purposes 
of  a  perfect  operation  :  the  second,  to  have  the  walls 
and  border  of  the  cavity  in  such  a  condition  that  an 
efficient  filling  can  be  made;  and  the  form  and  beauty 
of  the  tooth  should  he  scrupulously  preserved  and 
protected,  so  far  as  the  above  requirements  will  per- 
mit. 

The  excavation  of  these  cavities  requires  very  deli- 
cate and  skilful  manipulation,  since  they  are  very 
readily  injured  by  cutting  too  much  or  at  a  wrong 
point.  All  decayed  and  discolored  portions  must  h«' 
entirely  removed,  as  well  for  the  appearance  of  the 
tooth  as  for  the  permanency  of  the  operation ;  after 
which  the  cavity  is  to  he  formed  with  greal  care. 
Toward  the  cutting  edge  of  the  tooth  the  dentine 
often  lias  all  been  displaced  by  decay,  Leaving  only 
the  two  plates  of  enamel  joined  at  the  edge,  and  thus 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  245 

forming  an  acute  angle,  the  obliteration  of  which  is 
always  attended  Avith  risk,  unless  great  care  is  ex- 
ercised, and  in  many  teeth  it  is  wholly  impractica- 
ble ;  and  still  it  is  difficult  j)erfectly  to  fill  such  an 
acute  angle.  The  inclinations  of  the  inner  and  the 
outer  walls  of  the  cavity  when  it  is  prepared,  will  de- 
pend on  its  size ;  when  it  is  small  or  medium  they 
may  be  parallel,  or,  if  necessary,  slightly  divergent 
inward ;  but,  when  large,  it  is  better  not  to  cut  much 
of  the  healthy  dentine  from  them,  lest  they  be  thus 
weakened.  Small  grooves,  however,  are  admissible  on 
these  walls,  near  the  bottom  of  the  cavity,  when  they 
incline  to  the  centre,  and  are  generally,  in  such  case, 
to  be  preferred  to  pits.  In  the  formation  of  grooves 
or  pits  for  anchorages,  the  dentine  should  never  be 
cut  through  to  the  enamel,  but  always  dentine  suffi- 
cient to  protect  the  enamel  should  remain.  More 
cutting  is  allowable  on  the  cervical  wall  than  else- 
whore,  as  there  is  less  danger  here  of  weakening  the 
tooth  by  excavation.  In  some  instances  the  cavity 
upon  the  removal  of  the  decay  is  of  such  extent  and 
form  as  to  admit  of  little  or  no  excavation,  except  in 
the  cervical  wall;  in  this,  then,  the  chief  anchorage 
is  to  be  made,  and  almost  the  entire  reliance  for  the 
retention  of  the  filling  must  be  placed  upon  that  part. 
Such  a  condition  renders  the  use  of  cohesive  gold  a 
necessity,  at  least  if  a  permanent  result  is  to  be  at- 
tained.     The  best  method  of  preparing  such  a  cavity 


246  CLASSIFICATION    OF    DECAYED    CAVITIES. 

is  to  make  two  or  three  little  pits  in  it.  al  differenl 
angles,  with  a  fine,  square-pointed  drill.  Another 
method  is  to  form  two  pits,  and  make  a  groove  from 
one  to  the  other.  Some  operators  prepare  these  cavi- 
ties by  making  pits  in  each  of  the  walls.  This, 
however,  is  unnecessary,  it'  the  cervical  wall  is  prop- 
erly prepared. 

Id  the  application  of  the  rubber  dam  for  filling  this 
class  of  cavities,  three,  four,  or  more  teeth  should  gen- 
erally be  included,  in  order  thai  there  shall  be  abso- 
lute security  against  moisture,  and  thai  the  rubber 
shall  be  out  of  the  way  of  the  operation.  The  gold, 
prepared  as  already  described,  should  then  be  intro- 
duced with  a  small  plugger,  serrated  and  somewhat 
flattened  aboul  a  line  above  the  point,  so  as  to  be 
freely  used  when  introduced  into  the  cavity.  The 
gold  is  taken  up  on  the  point  of*  this  plugger,  and 
condensed  in  the  pits  of  the  cervical  wall,  which,  being 
completely  filled,  and  the  gold  extending  from  one  to 
the  other,  the  foundation  is  ready  for  the  remainder 
of  the  filling. 

Care  is  requisite  in  packing  the  gold  into  these  cav- 
ities perfectly  to  adapt  and  adjust  it  to  all  points,  so 
as  to  insure  its  thorough  contact  with  every  part  of 
the  interior.  If  the  form  of  the  tooth  lias  been 
measurably  retained,  and  the  border  of  the  cavity  is 
even,  the  surface  of  the  plug  should,  when  finished, 
be  slightly  convex,  or  as  nearly  the  original  form  of 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  247 

the  tooth  as  practicable.  In  introducing  the  filling 
reference  should  be  had  to  this  particular.  Two-thirds 
of  the  cavity  may  be  filled  by  introducing  the  gold 
upon  and  in  the  direction  of  this  cervical  wall,  and 
the  remaining  portion  filled  from  the  point  back  to 
the  preceding  filling ;  or,  what  is  probably  better,  be- 
gin at  the  bottom  and  fill  to  the  surface,  and  then 
finish  in  the  usual  manner. 

For  filling  these  cavities  with  non-cohesive  foil,  the 
special  retaining-points  already  described  are  not  re- 
quired ;  but  the  cervical  wall  of  the  cavity  is  slightly 
cut  under,  and  the  lateral  walls  so  shaped  as  to  se- 
cure the  filling  in  place.  These  cavities  are  in  some 
cases  very  difficult  to  fill  with  non-cohesive  foil, 
whether  in  the  form  of  blocks  or  otherwise,  especially 
where  they  are  large,  with  the  walls  inclined  to  the 
(•(•ntre,  and  the  tooth-bone  friable.  To  force  a  wedge- 
shaped  instrument  into  these  fillings,  for  the  pur- 
pose of  condensing  them,  is  not  admissible,  since  there 
is  thus  great  danger  of  breaking  the  walls  of  the 
cavity,  and,  in  many  cases,  of  moving  the  filling  from 
its  place. 

1st  Mod. —  The  palatal  ivalls  broken  away. — Frac- 
tures of  this  kind  assume  different  forms,  sometimes 
triangular,  extending  from  the  border  of  the  cavity 
toward  the  centre  of  the  tooth,  and  terminating  in  an 
acute  angle,  and  sometimes  the  border  of  the  cavity  is 
broken  away  irregularly,  .-<>  as  to  form  part  of  a  circle. 


248  CLASSIFICATION    OF    DECAYED   CAVITIES. 

AVhen  a  triangular  notch  is  broken  out  of  the  wall 
the  operation  of  filling  may  be  performed  in  one  of 
two  ways.  If  the  portions  of  the  wall  remaining  at 
each  side  of  the  fracture  are  thick  and  firm,  they  may 
be  left,  and  the  cavity  filled  so  as  to  restore  the  form 
of  both  the  proximate  and  the  palatal  surface  of  the 
tooth,  the  latter  being  thus  restored  with  gold  to  the 
extent  of  the  fracture  or  notch.  If,  however,  the  re- 
maining portions  of  the  wall  are  frail,  they  should  be 
cut  away  till  a  border  is  reached  sufficiently  firm'  to 
sustain  the  filling.  Such  cutting  will  leave  the  notch 
of  a  circular  form,  and  in  many  cases  will  remove 
almost  the  wdiole  of  the  inner  wall  of  the  cavity.  As 
the  decay  extends  toward  the  centre  of  the  tooth, 
owing  to  the  concavity  of  its  palatal  surface,  this 
wall  becomes  very  thin  and  easily  broken,  thus  ren- 
dering it  necessary  to  cut  it  almost  all  away ;  but  in 
all  cases  the  excavation  should  be  such  as  to  leave  a 
definite  wall,  though  it  be  but  slight,  all  along  that 
part  of  the  cavity.  In  such  a  case,  good  retaining- 
points  must  be  made  in  the  cervical  wall,  since  the 
permanency  of  the  filling  will  depend  almost  entirely 
upon  these. 

The  surface  of  the  filling,  when  finished,  may  be 
slightly  convex  from  one  lateral  wall  to  the  other  ;  the 
palatal  portion  of  the  surface,  from  the  point  of  the 
tooth  to  its  neck,  will  partake  of  the  curvature  of 
the  border  of  the  palatal  wall;  but  the  anterior  por- 


FILLING   BY   CLASSES    AND    MODIFICATIONS.  219 

tion  will  be  flush  with  and  assume  the  outline  of  the 
anterior  border  of  the  wall.  Much  care  is  requisite 
to  give  these  fillings  a  perfect  finish  on  account  of  the 
irregularity  of  surface,  this,  in  many  instances,  being 
both  convex  and  concave.  As  a  material  for  filling 
these  cavities  cohesive  gold  is  much  to  be  preferred. 
Indeed,  in  many  of  them  it  is  impossible,  with  non- 
cohesive  gold,  to  make  a  perfect  filling,  because  they 
have  no  general  embracing  form.  In  such  cases  the 
filling  should  be  introduced  from  the  palatal  side  of 
the  tooth. 

2d  Mod. —  The  labial  wall  of  the  cavity  broken. — 
The  fractures  of  this  wall  are  of  various  forms,  and 
in  extent  corresponding  with  the  amount  of  decay  and 
the  friability  of  the  enamel.  There  is  sometimes  the 
triangular  notch,  extending  far  toward  the  middle 
of  the  tooth;  and  sometimes  there  are  two  or  three 
small  notches;  and,  still  in  other  cases,  almost  the 
whole  of  the  wall  will  be  broken  away  from  the  point 
to  the  neck  of  the  tooth.  When  there  is  simply  a 
notch  in  the  enamel,  it  is  important  for  the  appear- 
ance of  the  tooth  to  fill  it  up;  and  when  there  is  any 
prospect  of  success,  the  remaining  portion  of  the  wall 
being  retained,  the  operation  is  to  be  performed  as 
already  described  tor  the  palatal  wall.  It  will,  how- 
ever, in  many  cases,  be  necessary  to  cut  away  part 
of  the  remaining  portions  of  tin-  wall,  leaving  the 
genera]  form  of  tin-  border  somewhat  circular,  though 


250  CLASSIFICATION    OF    DECAYED    CAVITIES. 

the  notch  form  in  some  instances  is  not  wholly  ob- 
literated. 

In  filling  this  kind  of  cavity  it  is  desirable  to  re- 
store as  much  as  possible  the  form  of  the  tooth.  The 
filling  should  be  buill  oul  from  the  border  of  the  wall 
almost  to  a  line  with  the  tooth's  original  proportions, 
so  thai  the  whole  surface  of  the  filling  will  be  convex ; 
and  it  should  be  finished  with  special  care,  the  Scotch 
stone,  buff,  or  stipple  finish  being  preferable  for  that 
pari  exposed  to  view. 

3d  Mod. —  The  cavity  extending  almost  to  the  point 
of  the  tooth,  and  terminating  or  running  out  at  the 
surface. — In  the  preparation  of  this  cavity  thai  pari 
next  the  point  of  the  tooth  should  be  cut  in  enough 
to  form  a  definite  wall  there,  and  to  give  room  for 
sufficient  thickness  and  strength  in  that  portion  of 
the  plug.  Many  operators  attempt  to  fill  this  kind 
of  cavity  without  such  precaution,  terminating  that 
part  of  the  plug  in  a  thin  edge.  This  method  is  very 
objectionable,  for  the  thin  edge  will  become  more  or 
less  separated  from  the  tooth,  and  foreign  substances 
will  be  forced  under  it,  and,  becoming  vitiated,  induce 
decay.  Indeed,  a  defect  of  this  kind  is  a  sure  pre- 
cursor of  the  destruction  of  the  filling.  The  intro- 
duction and  finish  of  the  rilling  in  this  kind  of  cavity 
are  the  same  as  first  described  for  this  class;  and  the 
admonition  may  be  repeated,  that  there  be  left  no  thin 


FILLING   BY   CLASSES   AND    MODIFICATIONS.  251 

overlappings  of  the  filling  that  may  become  changed 
in  position. 

4th  Mod. —  The  cavity  large,  and  the  lateral  walls 
thin  and  friable. — In  this  kind  of  cavity  the  dentine 
is  almost  entirely  removed  from  the  lateral  walls, 
leaving  little  more  than  the  enamel  after  the  excava- 
tion of  the  decay.  These  walls  will,  of  course,  admit 
of  no  cutting  for  the  purpose  of  giving  them  a  more 
desirable  form.  The  cervical  wall  must  be  shaped 
with  special  reference  to  a  retention  of  the  filling,  to 
consolidate  which  the  requisite  pressure  must  be  ap- 
plied almost  exclusively  toward  this  wall.  It  requires 
great  care  to  condense  the  gold  in  cavities  of  this 
kind  and  adapt  it  to  the  lateral  walls  without  frac- 
turing them ;  various  methods  have  been  suggested 
to  prevent  such  an  accident.  Pluggers  with  very  fine 
points  are  recommended,  as  consolidating  the  gold 
with  much  less  pressure  than  would  be  necessary 
with  large-pointed  instruments.  But  it  has  been 
maintained  that  a  perfect  adaptation  of  the  gold  to 
the  inner  parts  of  these  walls  is  not  important,  pro- 
vided the  adaptation  at  the  border  is  perfect.  It  is 
certain,  however,  that  a  filling  thus  imperfectly 
adapted  is  not  so  good  as  though  the  gold  were  in 
contact  with  all  points  of  the  cavity;  and  besides, 
tli<-  liability  of  fracturing  the  wall  is  just  as  great  in 
Consolidating  at  the  border  as  within.  The  walls  may 
be  sustained  by  enveloping  the  tooth  to  the  borders 


252  CLASSIFICATIOM    OF    DECAYED    CAVITIES. 

of  the  cavity  with  some  material  perfectly  adaptable 
to  it,  and  capable  of  resisting  the  force  applied  in  the 
process  of  consolidation,  as  gutta-percha  or  plaster  of 
Paris.  If  the  former  is  employed,  it  should  be  soft- 
ened by  warming,  moulded  upon  the  tooth,  and  then 
permitted  to  harden.  The  hardening  may  be  facili- 
tated by  throwing  cold  water  on  it  from  a  syringe. 
It  is  then  to  be  trimmed  even  with  the  border  of  the 
cavity,  so  as  to  admit  the  filling.  If  plaster  of  Paris 
is  to  be  used,  it  should  be  of  the  best  quality.  Ye\ 
gutta-percha  is  to  be  preferred.  In  these  fillings  when 
the  enamel  is  clear  and  translucent  the  gold  will  be 
visible  through  it.  Toobviate  this  difficulty, and  give 
strength  to  the  trail  walls,  after  the  cavity  is  formed 
and  thoroughly  cleansed,  it  should  be  filled  with  oxy- 
phosphate  of  zinc.  Care  must  be  exercised  in  intro- 
ducing this  to  secure  its  perfect  adaptation  to  every 
pari  of  the  cavity;  and  after  hardening  has  taken 
place  excavate  as  may  be  requisite,  leaving  enough  to 
constitute  a  good  lining  and  support  to  the  thin  walls, 
and  obscure  the  view  of  the  gold. 

The  natural  color  of  the  tooth  may  be  in  this  way 
so  well  restored  and  maintained  as  to  elude  detection. 
At  the  border  of  the  orifice  the  gold  should  come  in 
contact  with  the  dentine  or  enamel.  In  almost  all 
cases  of  thin  weak  borders  the  gold  should  be  built 
on  and  over  them,  so  as  to  form  a  shield  or  protection 
againsl  fracture  or  undue  wear.     AH  such  overlapping 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  253 

portions  should  be  made  so  thick  and  firm  as  not  to  be 
displaced  or  moved. 

The  loss  of  a  portion  of  the  cutting  edge  of  the  in- 
cisors by  extensive  decay  is  often  met  with.  In  all 
such  cases  when  the  dentine  is  of  good  structure,  it 
is  practicable  to  restore  the  lost  part  to  a  greater  or 
less  extent  by  building  up  with  gold.  In  order  to 
make  successful  operations  in  such  cases  several 
points  must  be  regarded.  The  dentine  and  enamel 
should  be  of  good  structure;  the  cavity  toward  the 
neck  of  the  tooth  of  such  a  form  as  to  afford  the  best 
anchorage;  this  may  consist  of  pits  with  grooves  run- 
ning out  from  them.  Teeth  with  thick,  short  crowns, 
present  the  best  opportunity  for  such  an  operation;  in- 
deed, upon  that  class  of  incisors  with  long  thin  crowns, 
such  an  operation  is  not  usually  practicable,  and  gen- 
erally these  teeth  present  such  a  contrast  in  color  with 
the  gold  as  to  be  quite  objectionable.  In  the  operation 
the  manipulation  must  be  such  as  to  secure  the  most 
thorough  welding  of  the  portions  of  gold  of  which  the 
filling  is  composed.  With  good  attachments,  gold 
well  prepared  and  in  good  condition,  and  properly 
manipulated,  the  filling  may  be  built  up  to  any 
desired  extent  without  danger  of  being  either  drawn 
out  or  broken  down.  The  finish  should  be  such  as 
has  already  been  described  for  fillings  exposed  to  view. 

Fifth  Class. — Postebiob  peoximate  cavities  of 
the  kolabs  A.\D  BICUSPIDS. — These  are  separated  like 


254  CLASSIFICATION   OF   DECAYED   CAVITIES. 

anterior  proximate  cavities,  except  that,  ordinarily,  to 
open  them  up  more  is  to  be  cut  from  the  tooth,  on 
account  of  the  greater  difficulty  of  approaching,  in- 
specting, and  operating  in  the  cavity.  The  same  gen- 
eral principles  are  applicable  to  the  opening  of  this 
class  of  cavities  as  to  that  of  the  third  class,  except 
that  pressure  for  separating  cannot  be  as  frequently 
employed,  since  the  cavity  will  not  be  as  well  exposed 
by  this  as  by  cutting,  nor  rendered  so  easy  of  ap- 
proach. Indeed,  in  operating  on  these  cavities,  the 
use  of  the  mirror  is  often  necessary,  it  being  impos- 
sible to  obtain  a  direct  view  into  them  after  having 
cut  away  all  that  it  is  admissible  to  remove.  This 
difficulty  is  almost  wholly  obviated  by  the  method  of 
working  through  the  masticating  surface  of  the  tooth 
into  the  cavity  of  decay,  as  already  described.  The 
accessibility  of  these  cavities  will  depend  on  circum- 
stances, such  as  the  location  of  the  tooth,  its  inclina- 
tion, the  size  of  the  mouth,  the  flexibility  of  the 
muscles,  and  the  ability  of  the  patient  to  open  the 
mouth  and  keep  it  open.  Generally  in  operating  on 
these  cavities  for  the  removal  of  decay,  for  the  forma- 
tion and  the  filling,  curved  instruments  will  be  re- 
quired, but  their  curvature  should  not  be  greater 
than  the  necessity  of  the  case  demands. 

The  cavity,  during  its  preparation,  must  be  fre- 
quently examined.  Its  general  form,  and  the  size, 
kind,  and  location  of  the  retaining-points,  will  be  the 


FILLING    BY   CLASSES   AND   MODIFICATIONS.  255 

same  as  in  class  third.  The  lateral  walls,  if  the  cav- 
itv  is  not  too  large,  should  be  made  parallel  with  each 
other ;  the  undercutting  at  the  crown  wall  will  be  less 
than  in  anterior  proximate  cavities;  and  the  cervical 
wall  should  have  a  slight  inward  inclination, — the  re- 
verse of  the  same  wall  in  anterior  proximate  cavities. 
In  this  latter  there  should  be  made,  at  different  angles, 
pits  for  retaining-points — three,  if  the  tooth  is  a  molar, 
and  two  if  a  bicuspid.  For  making  these  pits,  the 
engine  right-angle  hand-piece  will  be  found  applicable 
and  convenient. 

Preparatory  to  introducing  the  filling,  the  same  ap- 
pliances should  be  used  to  protect  the  cavity  from 
moisture  that  have  been  described  elsewhere.  Much 
care  should  be  exercised  in  introducing  and  securing 
the  first  portions  of  gold.  The  size,  form,  and  loca- 
tion of  the  anchorage-points  should  be  carefully  noted, 
and  into  these  the  filling  should  be  very  j)erfectly  in- 
troduced ;  here  the  most  thorough  welding  of  the  gold 
Bhould  be  made,  so  that  each  piece  when  adjusted 
will  be  immovably  fixed.  The  gold  extending  from 
one  anchorage  to  another  constitutes  the  foundation 
upon  which  the  subsequent  part  of  the  filling  is  to 
be  built.  This  may  proceed  uniformly  from  the  cer- 
vical part  of  the  cavity  to  the  masticating  surface  of 
the  crown,  if,  as  is  usual,  tin-  prepared  cavity  involves 
this  Bnrface. 

When  the  separation  made  between  the  teeth  con- 


256  CLASSIFICATION    OF    DECAYED    CAVITIES. 

stitutes  a  V-shaped  space,  the  filling  should  have  a 
single  plain  or  slightly  convex  surface,  which  will  be 
at  a  greater  or  less  angle  with  the  axis  of  the  tooth, 
according  to  the  greater  or  less  amount  cut  away  in 
the  separation.  Much  care  is  requisite  in  order  to 
make  perfect  work  along  the  borders  of  the  lateral 
walls  of  the  cavity;  these  should  be  secured  as  the 
work  progresses,  and  should  in  no  case  be  left  to 
receive  attention  after  the  body  of  the  filling  is  intro- 
duced. 

When  the  lateral  walls  have  been  cut  away,  as  was 
formerly  the  practice,  it  is  much  more  difficult  to  re- 
store the  crown  to  its  original  form  and  size  than  by 
the  method  now  pursued — retaining  the  lateral  walls 
and  filling  flush  with  them,  and  also  protecting  the 
edges  by  the  filling. 

It  is  claimed  that  the  difficulty  of  filling  this  class 
of  cavities  is  much  diminished  by  the  use  of  the  ma- 
trix. This  appliance,  in  its  present  form,  is  the  de- 
vice of  Dr.  Lewis  Jack.  He  gives  the  following 
description  of  it  and  its  use:  "These  little  affairs  are 
made  of  a  variety  of  shapes,  sizes  and  thicknesses. 
They  are  formed  of  slightly  wedge-shaped  pieces  of 
steel,  and  are,  as  the  cut  designates,  hollowed  out  at 
their  thicker  edge,  which  depression  terminates  at 
the  thinner  edge.  At  the  part  of  the  depression  de- 
signed to  give  shape  to  the  buccal  edge  of  the  filling, 
the  cut  is  generally  abrupt  and  deep;  at  the  inner  por- 


FILLING    BY    CLASSES   AND    MODIFICATIONS. 


257 


Fig.  91. 


tion  it  is  more  shallow  and  more  inclined.  It  will  be 
observed  that  the  depression  widens  as  it  passes  toward 
the  inner  edge  to  follow  the  usual  form  of  proximate 
cavities.  The  lower  and 
thin  edge  is  rounded,  to 
outline  the  curved  mar- 
gin of  the  cervical  walls, 
and  to  effect  pressure 
upon  either  the  gum  or 
the  appliances  used  to 
stop  the  escape  of  the 
mucus  and  blood  from 
this  tissue. 

"The  plain  parts  of 
the  face  are  file-cut,  or 
coarsely  draw-filed.  The 
reverse  side  is,  in  most 
-.  plain  and  smooth, 
excepting  a  small  por- 
tion   at   the   thin    edge, 

which  is  file-cut 

At  each  end  a  square  cut 
i-  made,  that  the  ends  of 
the   plier   for    adjusting 

them  will  fit  into v< 

Quite  a  number  of  pairs 
are  necessary  to  meet  the  requirements  of  the  differ- 
ent cases,  bul  for  the  ordinary-sized  simple  proximate 


CLASSIFICATION    OF    DECAYED    CAVITIES. 

cavities,  a  dozen  pairs,  varying  in  width,  in  thicki 
and  in  size  of  depression,  are  all   that    I    have   found 

ssary The  character  of  the  modifications 

thai  should  be  made  in  these  will  depend  somewhat 
upon  the  desired  end,  since  either  a  flat,  contour,  or 
excessively  convex  surface  may  be  produced  at  the 
pleasure  of  the  operator,  or  to  suit  the  needs  of  the 
individual  operation,  by  varying  the  form  and  depth 
of  the  depression." 

The  ordinary  forms  of  these  appliance-  arc  repre- 
sented by  Fig.  91. 

Some  additional  description  of  the  matrices,  and  the 
method  of  using  them,  will  be  given  in  the  Appendix, 
-      D. 

A  if  polished  metal,  of  the  proper  thickn 

may  be  placed  back  of  the  cavity  against  the  adjoin- 
ing tooth,  introducing  the  filling,  and  consolidating  it 
firmly  up  to  this  piece  of  metal.  The  lost  portion  of 
the  crown  being  thus  restored,  the  metal  is  then  re- 
moved and  the  filling  dressed  off  and  finished  in  the 
manner  described  heretofore. 

But  when  the  opening  is  made  by  cutting  in  from 
the  masticating  surface,  the  entire  opening  made  in 
the  tooth,  both  by  the  decay  and  the  operation,  will 
be  completely  filled  and  the  form  of  the  tooth  en- 
tirely restored;  the  filling  will  then  present  a  proxi- 
mate and  crown  surface.  When  the  teeth,  molars  ami 
bicuspids,  are  decayed  upon  their  contiguous  sides,  the 


FILLING   BY   CI  JID   MODIFICATIONS. 

cavities  in  both  may  be  prepared  as  already  descril 
the  proper   separation   and    excavation   having  been 
made.,  both  may  be  filled  together,  the  gold  extending 
across  the  space,  and  after  being  filled  up  flush  with 
the  masticating  surfaces,  the  separation  is  effected  by 
dividing  the  gold  with  a  separating  file.     Th 
cavity  is  completely  filled,  and   there  is  always  gold 
enough  on  the  proximate  parts  to  secure  a  complete 
finish.     This  method  is  not  always  practicable,  as.  for 
instance,  when  there  is  a  large  space,  or  when  it  is  not 
desirable  to  fully  restore  the  form  of  each  tooth;  but 
occasionally  it  may  be  used  to  advantage.     The  la 
tedium,  and  difficulty  of  manipulation  are  in 
the  farther  back  in  the  mouth  the  dec      is  situated. 
The  modifications  of  this  class  are  the  same  as  th   - 
of  the  third  class  of  cavities,  and.  except  the  second 
modification,   are   susceptible  of  the  same  methods 
filling. 

I  . — The  first  case  that  we  shall  con- 
.-  here  o  -  -  -  in  a  complication  of  proximate  de- 
cay, witli  decay  on  the  buccal  or  palatal  portion  of 
the  tooth,  thus  undercutting  one  of  the  crown  ang  - 
8  ictimes  these  decays  are  on  both  sides,  in  the  form 
of  transverse  grooves,  meeting  at  the  corner  of  the 
tooth.  In  such  cases,  if  the  pendent  crown-angle  of 
the  tooth  is  firm  and  strong,  the  cavities  may  be 
formed  in  the  proper  manner,  and  filled  without  in- 
terfering with  the  masticating  portion  of  the  tooth  at 


2G0  classification    OF    DECAYED   CAVITIES. 

all;  but  it'  the  pendent  portion  is  friable  it  should  be 
cut  away,  and  the  corner  built  up  with  gold.  The 
method  of  forming  the  part  to  be  filled  will  depend 
on  the  extent  of  the  decay.  .  When  this  is  large,  a 
greater  number  of  retaining-points  will  be  required 
than  when  it  is  small,  and  these  should  be  located  at 
such  parts  as  will  make  them  most  tenacious  of  the 
gold,  and  best  conserve  the  strength  of  the  tooth.  The 
filling  may  be  built  up  so  as  to  restore  the  original 
form  of  the  tooth,  thus  presenting  three  surfaces,  the 
proximate,  the  buccal  or  palatal,  and  the  masticatory; 
or,  it  may  be  made  with  a  single  slightly  convex  sur- 
face, adapted  and  finished  most  completely  at  all  its 
borders.  This  kind  of  filling  can  be  made  only  with 
cohesive  gold. 

The  palatal  portion  of  the  crown  broken  away,  leav- 
ing the  outer  portion  standing — pulp  not  exposed. — The 
tooth  in  such  case  is  decayed  away,  so  that  the  floor 
of  solid  dentine  is  near  the  margin  of  the  gum,  the 
labial  third  of  the  crown  still  standing.  The  decay 
having  been  all  removed,  four  or  five  little  pits  should 
be  made  on  this  floor,  as  near  its  circumference  as 
practicable,  and  a  small  groove  may  be  cut  from  one 
of  these  pits  to  another  all  round  near  the  edge  of  the 
floor.  Then  two  little  pits  should  be  made  at  the 
base  of  the  standing  portion  of  the  crown,  if  practi- 
cable, without  interfering  with  the  pulp,  provided  it  is 
still  living.     The  tooth  thus  prepared  and  properly 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  261 

pr<  >tected  by  the- use  of  the  rubber  dam,  the  filling  may 
proceed. 

For  building  up  a  crown  of  this  kind  only  cohesive 
gold  can  be  used;  and  this  should  be  of  the  best 
preparation,  and  in  the  most  perfect  condition,  since 
it  is  important  that  the  different  portions  of  the  filling 
be'  most  thoroughly  united.  The  instruments  em- 
ployed in  the  operation  should  be  of  the  best  kind, 
and  in  the  best  condition,  the  serrate  points  being- 
definite  and  sharp,  though  not  too  long;  those  with 
four,  six,  or  eight  points  may  be  advantageously  used 
for  packing  the  gold.  But  care  must  be  exercised  lest 
these  fine  points  be  turned;  for,  when  that  is  the  case, 
the  instrument  is  liable  to  displace  the  portion  of  gold, 
and  thus  break  up  its  first  attachment  during  the 
process  of  consolidation,  and,  when  this  is  broken,  the 
piece  of  gold  cannot  again  be  made  to  adhere  as  per- 
fectly as  before. 

With  everything  thus  in  readiness,  the  retaining- 
points  are  to  be  all  filled,  the  gold  extending  from  one 
to  the  other;  this  is  then  to  be  built  all  over  the  bot- 
tom of  the  pari  to  bo  restored,  projecting  a  little  beyond 
the  periphery,  and  being  perfectly  consolidated  there, 
and  kepi  somewhal  higher  round  the  border  than  in 
the  centre.  The  gold  should  be  built  up  in  this  man- 
ner till  the  crown  is  large  enough,  after  dressing,  to 
give  the  desired  wze  and  form.  In  finishing  up,  the 
aim  should  be  to  restore  as  perfectly  as  possible  the 


2G2  CLASSIFICATION   OF   DECAYED   CAVITIES. 

lost  form  of  the  tooth.  The  adaptation  of  the  gold 
to  the  standing  portion  of  the  crown  should  be  mosl 
complete;  imperfection  in  this  respect  impairs  the 
appearance  of  the  work,  and  jeopardizes  the  security 
of  the  operation. 

Occasionally  the  crown  of  a  molar  tooth  is  found 
decayed  off  all  round,  almost  to  the  margin  of  the  gum, 
the  pulp  having  previously  receded  so  as  not  to  be  ex- 
posed. It  is  in  such  case  desirable  to  restore  the  lost 
portion  of  the  crown,  and  make  a  masticating  surface 
such  as  shall  antagonize  properly  with  the  teetli  of  the 
opposite  jaw.  This  may  be  done  by  building  it  up 
with  cohesive  gold.  Or  a  better  method  is  to  make  a 
crown  of  gold  or  platinum  plate,  of  the  proper  form, 
and  attach,  as  will  be  described  in  the  chapter  on  arti- 
ficial crowns.  In  the  preparation  for  the  crown  of 
gold  foil,  the  edge  should  be  dressed  smooth  and  even 
all  round  the  tooth  ;  then  six  or  eight  deep  pits  should 
be  made  at  different  angles  on  the  base  thus  prepared ; 
and  they  should  be  bored  with  a  drill  larger  than  is 
commonly  used  for  retaining-points.  These  pits  may 
be  slightly  enlarged  within.  The  method  of  building 
up  the  crown  is  just  the  same  as  that  described  for 
building  up  part  of  a  crown,  the  pits  being  first  filled,, 
then  joined  together,  and  the  gold  extended  all  over 
the  part  to  be  covered  by  the  filling,  In  extending 
the  gold  from  one  retaining-point  to  another,  it  is 
necessary  to  build  up  to  a  considerable  thickness  above 


FILLING   BY   CLASSES   AND    MODIFICATIONS.  263 

the  orifice  of  the  pit.  The  portion  of  gold  extending 
along  on  the  tooth  from  the  pit  should  be  quite  thick 
and  firm,  so  as  not  to  curl  up  from  its  position  on  the 
addition  of  subsequent  portions.  Every  particle  of 
gold,  indeed,  should  be  so  manipulated,  that  it  will  se- 
curely maintain  its  first  position.  The  permanency  of 
the  operation  will  depend  very  much  upon  this  pre- 
caution. The  gold  should  extend  somewhat  beyond 
the  circumference  of  the  tooth  all  around,  in  order  to 
a  thorough  adaptation  and  finish. 

The  foundation  thus  prepared,  and  kept  free  from 
moisture,  the  crown  is  easily  built  up  by  the  ordinary 
method  of  j^acking  the 'gold.  Any  desired  shape  can 
be  given  to  this  artificial  crown  ;  but,  of  course,  that 
which  most  nearly  resembles  the  form  of  the  natural 
crown  is  in  all  cases  to  be  desired.  The  masticating 
surface  of  this  gold  crown  is  to  be  formed  from  the 
indications  given  by  the  antagonizing  teeth.  Such 
crowns  will  wear  for  years,  and  perform  all  the  func- 
tions of  the  natural  organs.  Artificial  crowns  of  this 
kind  have  been  attached  to  the  tooth,  by  screwing  into 
the  pits  small  pieces  of  gold  wire  at  different  angles, 
and  then  building  up  round  and  between  them  with 
the  gold  foil,  on  the  principle  already  described,  thus 
making  these  wire-  servo  as  so  many  anchors  for  fast- 
ening the  work.  The  use  of  screws  for  securing  fill- 
ings in  these  extreme  cases  was  suggested,  and  perhaps 
occasionally  used,  more  than  thirty  year-  ago,  by  Dr. 


26  I 


(  L  S.SS1  I'll  !  Vl'h  »N    OF    Dl'.i   A  VEI)    <    V  \  III  ES. 


W.  M.  Dwindle.  Bui  aboutten  years  ago  their  prac- 
ticability was  more  fully  demonstrated  by  Dr.  Mack, 
who  devised  a  set  of  instruments  by  which  small  gold 
-crews  can  be  very  readily  introduced  wherever  they 
arc  required.  These  screws,  as  made  by  Dr.  Mack,  are 
screw-cut  the  entire  length,  except  a  small  portion  of 
the  outer  end,  which  is  made  flat  and  wedge-shaped; 
upon  this  flattened  part  the  screw-driver  acts  when  the 
screw  is  introduced. 

Something  additional  in  this  direction  seemed  desi- 
rable, and  to  meet  this  want,  Dr.  E.  Osmond,  aboul  ten 
years  ago,  made  an  improved  screw,  and  constructed  a 
set  of  instruments  for  introducing  it.  These  are  rep- 
resented in  the  following  cut. 


Fig.  92. 


These  screws  are  made  of  twenty-carat  gold,  an- 
nealed and  split  about  halt-way,  once  or  twice,  so  as 
to  form  two  or  four  arms.  These  are  opened  and 
turned  down,  as  may  be  necessary  after  being  inserted. 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  265 

Thev  are  made  of  different  sizes,  to  meet  the  require- 
ments of  different  cases,  and  the  instruments  are  adap- 
ted to  the  different  screws.  The  teeth  represented  in 
this  cut  show  large  converging  cavities,  in  which  the 
screws  are  fixed,  ready  for  the  attachment  of  the  fill- 
ing. 

It  has  been  suggested  that  making  barbs  on  the 
screws  would  give  greater  security  to  the  filling  than 
the  plain  screw,  yet  with  Dr.  Osmond's  screws  the  ut- 
most security  is  attained.  Of  course  cohesive  gold  is 
always  to  be  used  with  this  kind  of  anchorage. 

Security  of  attachment  of  these  large  fillings  may 
in  many  cases  be  quite  as  well  attained  with  the 
foil  alone.  But  good  tooth-structure  and  properly- 
located  and  well-formed  anchorages  are  very  impor- 
tant. 

Filling  large  cavities  on  the  labial  surfaces  of  the 
superior  incisors. — These  cavities  are  usually  super- 
ficial, and  frequently  occupy  a  considerable  part  of 
tin-  Burface  of  the  tooth.  A  method  of  filling  them, 
somewhat  novel,  though  not  without  merit,  has  been 
introduced  to  the  notice  of  the  profession  by  Dr.  Volck, 
it  having  been  firs!  suggested  to  him,  however,  by  Dr. 
Maynard.  It  consists  in  filling  up  the  cavity  princi- 
pally with  ;i  piece  of  enamel,  ;is  near  the  color  of  the 
tooth    ;i-    possible.      Tin-   Cavity,    when    nearly    round, 

should  he  formed  with  a  wheel  bur  of  the  proper  size ; 
and  after  having  been  thus  reamed  out,  a  slight  under- 


266  CLASSIFICATION    OF    DECAYED   CAVITIES. 

cutting  should  be  made  all  round  with  an  excavator. 

Then  a  piece  of  enamel  being  selected,  it  is  dressed  to 
a  proper  thickness,  which  should  be  slightly  greater 
than  the  cavity's  depth,  and  to  a  perfectly  circular 
form,  its  size  being  such  as  to  let  it  drop,  with  a  little 
play,  into  the  cavity,  and  the  edge  of  it  bevelled  from 
"without.  For  fastening  this  in  the  cavity,  roll  a  strip 
( >t"  several  thicknesses  of  gold  foil  round  its  edge,  and 
add  as  much  as  can  be  forced  in  with  it.  Thus  pre- 
pared, set  it  in  place  in  the  cavity,  and  then  condense 
the  gold  down  into  the  groove  all  round  with  a  three- 
pointed  plugger,  more  gold  being  added,  if  necessary, 
to  fill  the  groove  completely  full.  Afterwards,  with 
the  file,  stone,  or  burnisher,  dress  off  the  whole  to  a 
proper  level  with  the  surrounding  tooth,  finishing  very 
carefully  with  the  burnisher.  The  unsightlinessof  a 
large  gold  filling  on  a  front  tooth  is  thus  obviated,  no 
metal  except  that  composing  the  ring  of  attachment 
in  the  groove  being  exposed  to  view\  It  is  a  beauti- 
ful operation,  and  one  whose  successful  accomplish- 
ment will  require  considerable  constructive  talent  and 

skill. 

A  better  method  of  performing  this  operation,  for 
many  cases,  at  least,  is  by  setting  a  porcelain  filling  or 
block  in  oxy-phosphate  of  zinc.  The  cavity  should 
be  prepared  as  usual,  the  borders  neatly  trimmed, 
and  made  as  free  as  possible  from  irregularities.  Se- 
lect a  section  of  a  porcelain  tooth  as  near  the  color 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  267 

and  surface  conformation  of  the  tooth  to  be  filled  as 
possible  :  then  fit  the  piece  to  be  supplied  carefully, 
making  it  to  conform  to  the  cavity  as  accurately  as 
possible ;  it  should  be  a  little  thinner  than  the  depth 
of  the  cavity.  The  cavity  now  being  secured  against 
moisture,  and  made  perfectly  dry,  oxy-phosphate  of 
zinc,  or  some  similar  plastic  material,  should  be  pre- 
pared of  such  a  consistence  as  to  permit  the  accurate 
adjustment  of  the  porcelain  filling.  This,  after  being 
put  in  place,  should  not  be  disturbed  nor  moistened 
till  the  cement  is  well  set.  It  is  better  to  cover  the 
joint  with  wax  or  varnish,  and  let  it  remain  a  day  or 
two,  before  attempting  to  dress  or  polish  the  porcelain  ; 
if,  however,  the  work  has  been  perfectly  done,  nothing 
else  will  be  required.  Porcelain  caps  or  cavity-stoppers 
are  now  made  by  manufacturers  of  teeth,  to  be  used 
in  these  cases,  and  in  the  same  way  as  above  described. 
They  are  made  in  sufficient  variety,  in  size,  form,  and 
color,  to  meet  every  case  in  which  such  an  operation  is 
admissible.  Fig.  93  will  give  a  correct  idea  of  these 
stoppers  as  now  prepared. 

There  will  be  in  almost  every  case  more  or  less  of 
fitting  and  adjusting  before  the  stopper  is  finally  set. 
Each  variety  is  made  with  notches,  slots,  or  grooves, 
in  order  that  they  may  l»<;  firmly  anchored  by  the 
cemenl  in  which  they  are  set. 

The  more  accurate  the  lit  of  the  cap  or  inlay,  the 
more  permanent  will  the  operation  be.     If  there  is  an 


268 


CLASSIFICATION   OF   DECAYED   CAVITIES. 


imperfect  adaptation,  the  space  between  the  cap  and  the 
margin  of  the  cavity  may  be  filled  with  gold.  This 
may  be  done  at  once  so  soon  as  the  cement  of  the  sit- 
ting is  sufficiently  solidified,  or  this  may  be  delayed 
until  the  cement  is  somewhat  worn  away. 


Fig.  93. 
Class  A. 


Class  B. 


)OCOOO 


Class  C. 


Class  D. 


in 


Class  E. 


An  operation  performed  in  this  manner  is  prefer- 
able to  a  filling  of  gold  for  this  class  of  cavities ;  it  is 
less  apparent  to  the  view  ;  indeed,  .when  a  proper  se- 
lection has  been  made,  and  the  adaptation  is  good,  it 
will  not  be  visible  at  all  except  under  the  closest  ob- 
servation ;  and  usually  the  tooth  will  be  as  well  pro- 
tected, and  in  many  instances  better,  than  by  the  com- 
mon method  of  filling. 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  269 

The  use  of  platinum  and  gold  foil  together,  as  sug- 
gested by  Dr.  Black,  for  filling  these  cavities,  is  better 
than  gold,  so  far  as  appearance  is  concerned  ;  the  strik- 
ing contrast  between  the  color  of  gold  alone  and  that 
of  the  tooth  is  materially  relieved. 


CHAPTER  VIII. 

PATHOLOGICAL   CONDITIONS. 

Hitherto,  in  the  consideration  of  the  treatment  of 
caries,  the  subject  of  the  vitality  and  pathological 
conditions  of  the  teeth  has  been  intentionally  omitted. 
It  now  remains  to  describe  the  diseased  conditions  to 
which  the  teeth  are  subject,  and  the  treatment  which 
these  respective  conditions  indicate.  This  is  an  im- 
portant department  of  the  practice,  since  upon  skill  in 
this,  as  well  as  upon  the  manner  of  performing  the 
work,  the  success  of  the  operation  depends. 

Premising  that  our  remarks  on  this  branch  of  the 
subject  are  predicated  on  the  fact  admitted,  that  the 
teeth  possess  vitality,  we  proceed  f-0  consider  the 
pathological  conditions  to  which,  in  common  with  all 
vital  tissues,  they  are  liable.  There  is  but  one  diseased 
condition  of  living  dentine,  anterior  to  decay,  that 
presents  any  considerable  difficulty  in  the  ordinary 
operation  of  filling  teeth,  and  that  is,  inflammation, 
or  exalted  sensibility.  This  condition  was  referred 
to  in  the  remarks  on  the  treatment  of  caries,  as  being 
one  that  most  generally  accompanies  decay  of  the 
teeth.  Whether  or  not  this  affection  is  real  inflam- 
mation, is  a  point  that  has  been  considerably  contro- 
verted ;  and  the  assertion  has  been  made  that  it  is  of  no 


SENSITIVE   DENTINE.  2"1 

consequence  whether  it  is  or  not,  provided  we  under- 
stand the  true  method  of  treating  it.  This,  however, 
is  not  to  be  so  readily  conceded ;  for  the  confession 
that  we  do  not  know  what  to  call  a  thine:,  2'enerallv 
implies  an  ignorance  of  its  character  and  phenomena. 
"While  the  term  inflammation  conveys  a  more  definite 
notion,  the  phrase  exalted  sensibility  is  very  vague  in 
meaning.  That  it  is  true  inflammation,  is  the  ojunion 
of  our  best  dental  writers. 

The  dentine  is  endowed  with  the  functions  of  ab- 
sorption, nutrition,  and  secretion,  modified  somewhat 
by  the  peculiarity  of  the  structure — characteristics 
that  always  imply  a  susceptibility  of  inflammation. 
In  inflammation  of  the  soft  parts  there  are  present 
various  indications, — as  pain,  redness,  swelling,  and 
increased  heat.  But  in  dentine,  on  account  of  its  pe- 
culiar structure,  all  these  indications  cannot  be  mani- 
fested; for  instance,  redness,  since  the  red  globules  do 
not  circulate  through  it;  nor  swelling,  since  the  struc- 
ture is  dense,  devoid  of  mobility;  nor  perceptibly  in- 
creased heat,  since  the  circulation  is  of  too  low  a 
grade.  But  one  of  the  most  definite  indications  of  in- 
flammation,  namely,  exalted  sensibility,  is  present  here 
in  a  very  marked  degree;  and  there  are  various  other 
circumstances  thai  indicate  this  condition  to  be  real 
inflammation;  the  same  irritating  causes  that  induce 
inflammation  in  the  more  highly  organized  parts, 
occasion   it   in  the  living  dentine.     This  condition  of 


27  J  PATHOLOGICAL   CONDITIONS. 

tiir  teetL  is  always  affected  by  a  general  inflammatory 
diathesis,  and  their  sensitiveness,  when  there  is  this 
general  tendency  to  inflammation,  is  always  increased, 

and  local  treatment  in  such  cases  will  commonly  he 
inefficient;  a  modification  of  such  a  condition  of  the 
system  produces  a  corresponding  change  in  the  af- 
fected teeth,  and  those  remedial  agents  which  are 
employed  in  the  topical  treatment  of  inflammation 
elsewhere  are  successfully  used  in  the  treatment  of 
inflamed  dentine.  From  all  these  circumstances  we 
infer  that  this  affection  of  the  teeth  is  a  real  inflam- 
mation. 

As  has  heen  already  remarked,  the  only  definite 
and  direct  indication  of  inflammation  of  the  dentine 
is  exalted  sensibility,,  though  this  is  not  an  imme- 
diate consequence  of  that  condition,  independent  of 
external  circumstances;  for  the  pain  resulting  directly 
from  inflammation  in  the  soft  parts  is  not  experienced 
here  by  reason  of  the  low  grade  of  vitality  and  the 
feeble  circulation.  But  the  teeth  in  a  state  of  inflam- 
mation will  suffer  pain  when  subjected  to  sudden 
variations  of  temperature,  whether  induced  by  the 
air,  by  fluids,  or  by  contact  with  any  hard  substance ; 
and  when  subjected  to  the  influence  of  agents  that 
irritate  the  nerve-tissue  anywhere,  such  as  acids,  some 
alkalies,  salts,  etc.  In  regard  to  degree,  extent,  and 
location,  this  affection  exhibits  a  variety  of  manifes- 
tations; in  degree  from  the  most  mild  to  the  most  in- 


SENSITIVE    DENTINE.  273 

tense — sometimes  fixed  at  a  uniform  degree  of  pain, 
and  sometimes  passing  through  the  gamut  of  torture 
up  to  the  most  acute  anguish.  The  character  of  the 
affection  is  modified  by  differences  in  the  organic  struc- 
ture of  the  teeth,  those  most  vascular  and  most 
highly  organized  being  most  readily,  and  most  exten- 
sively involved;  and  therefore  the  teeth  of  the  young 
are  generally  more  liable  to  it  than  those  of  the  old. 
So,  too,  persons  of  a  plethoric  or  a  strumous  habit,  as 
well  as  those  in  a  febrile  condition,  are  peculiarly 
predisposed  to  this  affection.  Sometimes  irritation 
or  disturbance  of  other  organs  of  the  system  sympa- 
thetically or  secondarily  induce  inflammation  of  the 
dentine.  Uterine  irritation  frequently  does  so,  and 
hence,  during  pregnancy,  or  a  rjrotracted  suppression 
of  the  catamenia,  the  teeth  are  very  liable  to  be 
tli us  affected,  and,  if  decayed,  to  become  very  sensi- 
tive. 

Inflammation  of  the  dentine  will  sometimes  be  ex- 
hibited in  various  degrees  in  different  teeth  in  the 
-;mie  mouth  at  one  time.  This  is  owing  to  differences 
in  the  organic  structure  of  teeth  developed  at  different 
periods  of  life,  to  differences  of  their  location  in  the 
mouth,  and  to  differences  of  exposure  to  those  agen- 
wliich  are  apt  to  induce  the  condition.  As  to  the 
extent  of  this  inflammation,  it  may  be  confined  to  a 
thin  lamina  of  bone  immediately  beneath  the  decom- 

I   portion,  or   may  extend  deep   into   the  body  of 
18 


274  PATHOLOGICAL   CONDITIONS. 

the  tooth,  and,  indeed,  in  some  cages,  pervade  the  den- 
tine of  the  entire  crown.  This  latter  extent,  how- 
ever, is  not  likely  to  occur,  unless  there  is  a  general 
predisposition;  if  it  is  produced  by  local  causes,  it 
will  not,  in  general,  penetrate  very  deeply  into  the 
dentine.  Most  commonly,  the  greatest  sensitive))' 
at  the  union  of  the  dentine  with  the  enamel,  but, 
sometimes,  it  is  confined  to  a  small  point  within  the 
cavity,  either  because  of  an  increased  susceptibility 
there,  or  because  there  has  been  a  concentration  of  the 
irritating  influences  to  that  point — the  former  being 
probably  the  more  frequent.  The  greatest  sensitive- 
ness, as  already  remarked,  is  generally  at  the  surface 
of  the  dentine,  because  that  is  the  termination  of  the 
nerve-fibrils  which  ramify  the  dentine,  and  wherever 
nerve-fibre  terminates,  there  always  we  may  look  for 
exalted  sensibility.  Hence  it  is  that  decay  of  the  teeth 
is  often  found  to  be  more  sensitive  in  its  incipient 
stages  than  when  it  has  become  more  advanced. 

Treatment  of  Inflamed  Dentine. — There  are  several 
methods  of  treatment  that  may  be  employed  to  rem- 
edy this  condition.  In  many  cases,  where  time  and 
circumstances  will  permit,  a  removal  of  all  irritating 
agents  from  the  affected  parts  will  enable  nature  to 
effect  a  restoration  to  health.  All  decomposed  den- 
tine is  to  be  removed  from  the  cavity,  every  exciting 
influence  in  it  withdrawn  or  neutralized,  and  the 
cavity  itself  perfectly  filled  with  some  non-conducting 


TREATMENT   OF   SENSITIVE    DENTINE.  275 

material,  so  as  entirely  to  exclude  all  foreign  sub- 
stances. So  far  as  non-conduction  of  heat  is  con- 
cerned, there  is,  perhaps,  nothing  better  than  "Hill's 
stopping;"  or,  in  some  cases,  tin  or  gold  may  be  used; 
but  when  either  of  these  is  employed  for  this  treat- 
ment some  non-conducting  substance  should  be  placed 
between  the  filling  and  the  sensitive  dentine.  The 
length  of  time  necessary  for  the  restoration  of  the  af- 
fected part,  under  this  treatment,  will  be  much  varied 
by  circumstances.  The  cases  susceptible  of  this  kind 
of  treatment  are  those  in  which  there  is  no  constitu- 
tional predisposition,  in  which  the  vitality  is  strong, 
and  the  recuperative  power  vigorous.  When  the  tem- 
porary fillings  are  made  of  metals,  the  patient  should 
be  careful  to  protect  them  from  sudden  changes  of 
temperature.  For  such  fillings,  in  case  they  are  re- 
quired but  for  a  short  time,  a  lock  of  cotton  saturated 
with  a  solution  of  gutta-percha  and  chloroform  may  be 
used. 

But,  in  cases  in  which  the  vitality  is  low,  the  af- 
fection chronic,  the  exciting  cause  highly  irritating, 
and  the  general  diathesis  inflammatory,  nature,  un- 
aided, will  not  effect  a  cure.  In  such  circumstances, 
therapeutic  treatment  is  indicated.  The  agents  em- 
ployed  in  topical  treatment  may  be  divided  into  two 
classes:  Bret,  resolvents,  or  those  which  have  for  their 
object  an  entire  restoration  to  health  of  the  part  af- 
fected; and,  second,  escharotics,  or  those  which  have 


21  6  I'M  HOLOGK  Al.   i  ONDITION8. 

for  their  objed  the  death  of  a  portion  or  all  of  the 
diseased  part.  The  former  class  of  agents  i-  of  course 
preferable,  when  the  objecl  can  be  promptly  accom- 
plished by  their  use,  and  especially  preferable  to  those 
agents  which  endanger  the  vitality  of  the  whole  tooth. 
In  very  many  cases  in  which  topical  applications  are 
indicated,  constitutional  treatment  is  also  required; 
and  this  should  be  of*  an  antiphlogistic  character. 
The  immediately  adjacent  parts,  too,  as  the  gums,  the 
mucous  membrane,  etc.,  should  be  carefully  regarded. 
Indeed,  treatment  of  the  gums  by  counter-irritation, 
depletion,  and  various  preparations,  such  as  the  con- 
ditions may  indicate,  will  often  be  found  prerequisite 
to  a  successful  treatment  of  sensitive  dentine  by  topi- 
cal applications. 

There  are  very  few  agents  used  simply  as  resolvents. 
The  properties  characteristic  of  this  class  of  agents 
are  tonic,  stimulant,  sedative,  and  astringent.  Cap- 
sicum may  fitly  represent  the  stimulant;  Peruvian 
bark  and  gum  myrrh,  the  tonic;  tannin  the  astrin- 
gent; and  opiates  the  sedative  principle.  Astringents, 
stimulants,  and  sedatives,  all  tend  to  counteract  in- 
flammation. The  agents  of  this  class  are  not  very  ex- 
tensively used  in  the  treatment  of  sensitive  dentine,  not 
because  they  are  not  ultimately  efficient,  but  because 
their  action  is  less  vigorous  than  that  of  some  other 
agents.       When,   however,    time   and    circumstances 


TREATMENT   OF   SENSITIVE    DENTINE.  277 

will  permit,  mild  treatment,  if  efficient,  is  to  be  pre- 
ferred. 

But  there  are  many  cases  in  which,  for  want  of  time, 
something  more  rapid  in  its  action  is  required.  Of 
this  character  is  the  second  class  of  therapeutic  agents, 
namely,  escharotics,  or  those  which  by  their  action  de- 
stroy a  portion  of  the  tissue  with  which  they  come  in 
contact.  It  may  be  well  to  notice,  separately,  the  prep- 
arations commonly  used  for  this  purpose. 

Tannin,  or  Tannic  Acid. — This  is  the  active  prin- 
ciple of  vegetable  astringents,  and  is  found  most  abun- 
dant in  nutgalls.  It  unites  with  albumen,  fibrin,  and 
gelatin,  forming  with  them  insoluble  tannates.  Its 
medicinal  influence  is  almost  necessarily  topical,  since 
the  promptness  of  its  action  on  albuminous  substances, 
and  the  insolubility  of  its  compounds  with  them,  pre- 
vent its  admission  into  the  general  circulation.  The 
action  of  tannin  on  dentine  lias  been  already  explained. 
Either  its  aqueous  or  its  alcoholic  solution  may  be  em- 
ployed, the  latter  being  the  better  and  more  convenient 
preparation.  It  is,  however,  recently  used  by  solution 
in  creosote  and  glycerin,  which  constitute  a  very  valu- 
able preparation.  Where  tannin  is  applied  to  dentine, 
there  is  formed  a  tannate  of  albumen,  which,  being  in- 
soluble, protects  from  irritation,  and  probably  incites 
to  healthy  condition  the  living  parts  beneath  it. 

Oreo8otef  and  Carbolic  Acid. — Formerly,  creosote 
was  obtained  by  distillation  of  wood,  and  differed  some- 


278  PATHOLOGICAL    CONDITIONS. 

whal  from  thai  in  present  use,  which  is  prepared  by 
distillation  of  coal  tar.  Ii  dissolves  freely  in  alcohol 
or  ether,  and  sparingly  in  water;  its  action  may, 
therefore,  be  modified  by  dilution.  Creosote  produces 
its  caustic  effects  by  its  affinity  for  albumen  and  gela- 
tin, with  which  it  forms  insoluble  compounds;  and 
from  its  modus  operandi,  it  is  evident  that  the  popu- 
lar opinion  thai  it  promotes  decay  of  the  teeth  is  an 
error. 

Nitrate  of  Silver. — This  salt  is  a  powerful  caustic, 
whether  applied  to  soft  parts  or  to  bony  tissue.  Its 
action  is  somewhat  complex.  Nitric  acid  is  liberated 
by  tlic  decomposition  of  the  -alt  when  in  contact  with 
organic  matter,  and  especially  bone  or  dentine.  Ni- 
trate of  silver  lias  a  strong  affinity  for  albumen,  unit- 
ing witli  it  without  difficulty  ;  and  the  compound  thus 
formed  is  soluble  in  nitric  acid.  When  the  nitrate  is 
applied  to  the  skin,  the  immediate  result  is  a  whitish 
mark  caused  by  a  union  of  the  salt  with  the  albumen 
of  the  cuticle ;  but  this  soon  turns  black,  by  the  re- 
duction of  the  salt  and  the  liberation  of  the  oxide  of 
silver,  when  for  each  atom  of  this  set  free  there  is  lib- 
erated an  equivalent  of  nitric  acid.  There  is  here, 
then,  an  agent  that  acts  promptly  on  the  gelatinous 
portion  of  the  tooth,  destroying  its  vitality  to  the  ex- 
tent of  the  combination  which  takes  place,  and  that, 
by  the  decomposition  of  part  of  the  salt,  and  the  con- 
sequent  liberation    of  part   of  the  acid,  also  acts  with 


TREATMENT    OF    SENSITIVE    DENTINE.  279 

energy  on  the  calcareous  portion.  The  compound 
formed  by  the  nitrate  with  the  organic  constituents  of 
the  tooth,  is  insoluble  except  with  a  Few  substances,  and 
therefore  protects  the  subjacent  parts  ;  and  the  pre- 
cipitation of  the  reduced  oxide  on  the  surface,  it  is 
claimed,  affords  some  additional  protection.  The  in- 
solubility of  the  compound  above  mentioned  prevents 
an  absorption  of  the  nitrate  by  the  dentine,  and  renders 
its  action  necessarily  superficial.  When  the  nitrate  is 
neutralized  by  a  union  with  it  of  an  equivalent  of  the 
constituents  of  the  dentine,  no  further  chemical  action 
is  possible.  The  compound  formed  by  this  union  is 
solid ile  in  a  dilution  of  the  nitrate;  and  if  this  be  ap- 
plied in  too  great  a  quantity,  there  may  be  a  larger 
Loss  of  substance  than  is  desirable  or  at  all  necessary  ; 
for  as  long  as  free  nitrate  remains  in  solution  in  the 
cavity,  the  insoluble  compound  is  not  precipitated,  and 
the  surface  is  therefore  exjoosed  to  the  continued  ac- 
tion. It  is  preferable  to  employ  the  nitrate  in  the  solid 
state,  or,  when  this  is  not  practicable,  in  a  concentrated 
solution,  and  -mall  quantity,  rather  than  in  a  copious 
dilution  and  repeated  application. 

From  the  observations  already  made,  it  is  quite 
evident  that  no  harm  can  result  to  the  tooth  from  a 
proper  application  of  this  agent,  beyond  the  portion  of 
it  immediately  acted  upon.  The  nitrate  cannot  be 
absorbed  by  dentine,  but  it  stimulates  the  subjacent 
dentine  to  more  healthy  action  ;  though  some  main- 


280  PATHOLOGICAL   CONDITIONS. 

tain  thai  it  is  not  as  efficient  in  this  respecl  as  some 
proper  chloride.  It  acts  to  a  greater  depth  than  tan- 
nin or  creosote,  but  not  so  deep  as  chloride  of  zinc,  nor 
with  so  much  pain.  Great  care  should  be  exercised 
that  it-  contacl  be  permitted  no  further  than  it.-  action 
is  desired. 

Chloride  of  Zinc. — This  agent  has  been  extensively 
used  in  the  treatment  of  sensitive  dentine,  though 
much  loss  now  than  formerly.  It  exerts  an  antiseptic 
and  disinfectant,  as  well  as  an  escharotic,  influence. 
In  its  operation  it  decomposes  ;  the  chlorine  obtaining 
hydrogen  by  decomposition  of  water,  hydrochloric  acid 
is  formed  ;  this  unites  with  the  calcareous  elements, 
and  breaks  down  the  animal  constituent  as  well.  It  is 
milder  in  solution  than  in  solid,  and  less  efficient  and 
Li  ss  painful.  It  is  soluble  in  water,  alcohol,  ether,  or 
chloroform.  The  ethereal  and  the  chloroformal  solu- 
tions are,  in  their  action,  least  painful  of  all  the  forms 
in  which  this  chloride  is  applied.  The  union  of  this 
agent  with  the  gelatinous  constituent  of  the  tooth  is 
also  more  prompt  in  solution  than  in  solid.  The  ether 
and  the  chloroform  may  lessen  the  pain  by  their  anaes- 
thetic influence.  In  the  use  of  the  chloride,  or  any 
other  active  caustic,  it  is  important  to  bear  in  mind  the 
exalted  vitality  which  follows  its  application  ;  and  the 
ojieration  should  be  immediately  performed.  In  the 
teeth  of  young  persons,  or  those  in  which  the  animal 
constituents  greatly  predominate,  the  vitality  will  be 


TREATMENT   OF   SENSITIVE    DENTINE.  281 

more  promptly  aroused  than  in  those  of  an  opposite 
texture,  and  the  change,  too,  will  be  greater.  If  the 
inflammation  is  confined  to  a  thin  lamina,  it  will  be 
almost  instantly  allayed  by  the  amplication  of  the  chlo- 
ride, and  the  cavity  may  be  excavated  as  though  there 
had  never  been  exalted  sensibility  in  it ;  but  if  the  op- 
eration be  delayed  any  considerable  time,  the  tooth  will 
often  be  found  in  a  worse  condition  for  excavating 
than  before  the  application.  The  remarks  on  absorp- 
tion under  the  head  of  nitrate  of  silver  apply  with 
equal  force  here :  there  is  not  the  least  danger  from 
this  source ;  indeed,  there  can  be  none,  even  when  the 
chloride  is  applied  to  the  soft  j)arts. 

Terchloride  of  Gold. — Of  this  preparation  the  ethe- 
rial  solution  only  has  been  employed.  This  acts 
with  great  promptness  on  the  dentine,  forming  an  in- 
soluble compound  with  the  gelatinous  elements,  and 
the  chlorine  performing  its  role  upon  the  calcareous 
portion.  On  account  of  the  promptness  with  which 
this  agent  operates,  neither  the  pain  nor  the  disturb- 
ance of  the  subjacent  parts  caused  by  it  is  great.  This 
substance  is  very  liable  to  decomposition.  By  expo- 
sure  to  air  or  light,  the  gold  is  precipitated  in  the 
metallic  form.  But  protected  from  these,  it  may  be 
preserved  for  a  long  time.  This  agent  will  not  be 
absorbed  by  tin-  dentine. 

Arseniowi  Acid. — The  modus  operandi  of  this  agent 
is  involved  in  obscurity.    In  regard  to  its  topical  ac- 


282  PATHOLOGICAL   CONDITIONS. 

tion,  Professor  Bachc  says:  "Arsenious  acid,  wlien  it 
produces  the  death  of  a  part,  docs  not  act,  strictly 
speaking,  as  an  escharo tic ;  it  destroys  the  vitality  of 
the  organized  structure,  and  its  decomposition  is  the 
consequence.  The  true  escharotic  acts  chemically, 
producing  a  decomposition  of  the  part  to  which  it  is 
applied, — a  state  incompatible  with  life."  Pereira 
says  :  "  Though  employed  as  a  caustic,  yet  the  nature 
of  its  chemical  influence  on  the  animal  tissue  is  un- 
known ;  hence  it  is  termed  by  some  a  dynamic  caus- 
tic." Its  escharotic  power  certainly  bears  no  propor- 
tion to  its  devitalizing  power  ;  but  it  is  probable  that  it 
forms  definite  compounds  with  some  of  the  constituents 
of  living  tissue;  and  if  so,  these  compounds  appear 
to  be  readily  and  rapidly  decomposed,  so  that  the 
acid  becomes  again  free  to  attack,  with  similar  results, 
the  subjacent  parts.  The  topical  application  of  ar- 
senic is  liable  to  be  followed  by  constitutional  effects. 

All  dentists  are  aware  of  the  fact  that  a  tooth-pulp 
may  be  destroyed  by  arsenic,  through  a  wall  of  con- 
siderable thickness.  To  accomplish  this,  the  agent 
must  in  some  way  penetrate  the  substance  of  the 
dentine,  and  its  vitality  is  destroyed  so  far  as  it  is 
thus  penetrated  ;  indeed,  the  vitality  of  the  whole 
crown  of  the  tooth,  both  dentine  and  pulp,  is  often 
destroyed  by  the  use  of  this  remedy,  applied  even  to 
a  small  cavity.  Exalted  sensibility  of  dentine  is  sub- 
dued by  this  agent,  more  by  devitalizing  than  through 


TREATMENT   OF   SENSITIVE   DENTINE.  283 

its  chemical  energy.  It  is  soluble  in  creosote  and 
similar  oils,  and  to  a  considerable  extent  in  alcohol 
and  water.  It  is  absorbed  much  more  rapidly  when 
applied  in  solution  than  in  solid ;  and  the  more  vas- 
cular the  dentine,  the  more  rapid  and  extensive  will 
be  the  absorption  ;  and  on  this  account  there  is  great 
risk  in  applying  it  to  the  teeth  of  young  persons,  or 
to  any  teeth  that  are  highly  wanting  in  density ;  in- 
deed, it  will  destroy  the  vitality  of  very  dense  teeth. 
The  manner  in  which  it  passes  into  the  dentine  is  not 
definitely  understood.  It  is  very  certain,  however, 
that  in  more  highly  organized  parts  it  is  carried 
through  by  the  circulation,  and  also  may  be  taken  up 
by  imbibition.  In  the  latter  of  these  ways  it  passes 
into  the  dentine.  It  is  enough  to  know  that  there  are 
well-defined  cases  of  its  specific  effect  on  the  constitu- 
tion, after  having  been  applied  to  dentine,  demonstrat- 
ing that  it  must  have  been  taken  up  by  the  circula- 
tion ;  and  also  cases  of  its  manifest  effect  on  the  peri- 
osteum in  a  short  time  after  having  been  applied  to 
the  cavity  of  a  tooth  the  pulp  of  which  is  dead — thus 
proving  that  it  must  have  been  absorbed  by  imbibition. 
If  arsenic  is  ever  employed  in  the  treatment  of 
sensitive  dentine,  it  should  be  suffered  to  remain  in 
the  cavity  but  a  short  time, — from  one  to  three  hours, 
— and  then  the  pari  wit )  i  which  it.  \v;is  in  conflict 
should  be  very  thoroughly  excavated.  In  deciding 
in  wlini  case  it    is  proper  u>  use  it,  there  i-  need  of 


284  PATHOLOGICAL   CONDITIONS. 

careful  discrimination  as  to  the  tooth's  structure  and 
density,  for  injurious  results  have  sometimes  followed 
its  application,  notwithstanding  the  utmost  care  ;  if  it 
has  once  passed  into  the  dentine,  antidotes  will  avail 
nothing.  On  the  whole,  therefore,  it -is  better  to  re- 
frain from  its  use  altogether  in  the  treatment  of  sen- 
sitive dentine. 

Alkaline  caustics  have  been  to  some  extent  used  for 
the  treatment  of  this  affection.  A  preparation  made 
after  the  following  formula  is  said  to  relieve  some 
cases  very  promptly:  Take  Canada  balsam  and  slacked 
lime,  and  having  made  them  into  a  paste,  fill  the  cav- 
ity with  it,  and  permit  it  to  remain  until  the  object  is 
accomplished. 

The  sensitiveness  of  dentine .  may  be  obtunded  by 
friction  on  the  affected  part  with  a  smooth  burnisher. 
This  method,  however,  is  applicable  only  to  those 
cases  in  which  there  is  room  to  use  the  instrument. 
On  the  surfaces  of  the  teeth,  where  there  may  be  sen- 
sitiveness, it  is  very  applicable  and  very  efficient. 
Simple  pressure,  without  friction,  it  is  suggested,  will 
accomplish  the  same  object,  though  pressure  and  fric- 
tion combined  are  doubtless  more  efficient. 

During  the  last  three  or  four  years,  various  appli- 
cations have  been  introduced,,  and  used  to  greater  or 
less  extent,  for  the  relief  of  sensitive  dentine  during 
the  operation  of  filling.  Moistening  a  cavity  with 
creosote,  carbolic  acid,  carvacrol,  or  oil  of  cloves,  at  the 


TREATMENT    OF   SENSITIVE    DENTINE.  285 

time  of  operating,  and  especially  in  excavating,  will 
in  many  instances  greatly  mitigate  the  pain,  and  in 
some  relieve  it  altogether.  Many  preparations  have 
been  devised  and  used  for  obtunding  or  destroying  the 
sensitiveness  of  inflamed  dentine ;  some  of  them  have 
been  quite  efficient. 

The  following  preparations  have  been  used  and  are 
valuable  in  the  topical  treatment  of  sensitive  dentine, 
creosote,  carbolic  acid,  oil  of  cloves,  oil  of  cedar,  oil 
of  eucalyptus,  and,  indeed,  most  of  the  essential  oils, 
glycerin  and  tannin,  creosote  and  tannin. 

Various  compositions  are  made  with  these,  and  sim- 
ilar ingredients,  nearly  all  of  which  are  valuable. 
Glycerin  and  carbolic  acid  solution  may  be  used  with 
very  good  effect  when  heated ;  it  should  be  applied  at 
first  at  such  a  temperature  as  to  produce  little  or  no 
pain,  and  the  heat  increased  as  the  applications  are 
renewed,  until  the  desired  effect  is  produced. 

Camphor  and  chloral  solution  is  used  in  some  cases 
with  good  results. 

It  is  well  to  bear  in  mind,  however,  that  no  one 
preparation  meets  the  requirements  of  every  case; 
some  will  accomplish  the  desired  result  in  one  case, 
and  be  wholly  inefficient  in  another. 

The  use  of  any  of  these  things,  even  though  they 
would  in  any  case  give  temporary  relief,  do  not  meet 
the  difficulty  in  a  proper  manner,  except  in  those 
cases  in  which  the  affection  is  very  superficial ;   in 


286  PATHOLOGICAL   CONDITIONS. 

every  other  case  the  aim  should  be  complete  restora- 
tion to  a  normal  condition,  and  this  for  the  most  part, 
;il  least,  must  he  accomplished  by  nature,  aided,  so  far 
as  practicable,  by  proper  systemic  and  local  treatment. 
Many  suppose  that  if  they  can  by  any  temporary 
obtunding  of  sensibility  introduce  a  filling,  all  will  be 
well.  This  sometimes  proves  to  be  a  serious  mistake, 
for  when  a  tilling  of  metal  is  placed  on  sensitive  den- 
tine, the  thermal  changes  very  often  prevent  a  re- 
turn to  a  normal  condition,  and  in  some  cases  greatly 
increase  the  difficulty.  In  all  instances,  so  far  as  pos- 
sible,  an  entire  restoration  to  a  state  of  health  should 
be  effected  before  filling,  or  the  part  shielded  by  a 
non-conductor. 


CHAPTER  IX. 

EXPOSED     PULPS. 

When  the  pulps  of  the  teeth  are  exposed  it  is 
usually  in  consequence  of  decay,  but  sometimes  of 
a  gradual  wearing  down  of  the  organs  in  mastication; 
in  other  cases  by  chemical  abrasion.  When  the  pulp 
of  a  tooth  is  found  exposed,  the  course  of  treatment 
to  be  pursued  will  be  indicated  by  the  following  con- 
siderations : 

1st.  The  constitution  and  the  vital  energy  of  the 
system. 

2d.  The  condition  of  the  mouth  and  teeth. 

3d.  The  condition  of  the  pulp. 

4th.  The  size  of  the  orifice  at  which  it  is  exposed. 

5th.  Whether  the  exposure  is  of  recent  or  of  re- 
mote origin. 

6th,  If  in  a  tooth  of  more  than  one  root. 

7th.  The  position  of  the  tooth  in  the  mouth,  and 
that  of  the  decayed  cavity  in  the  tooth. 

The  propriety  of  attempting  to  preserve  the  vi- 
tality of  the  pulp  after  exposure  has  been  questioned. 
Some  take  the  position  that  after  the  development 
:hk1  formation  of  the  tooth,  the  pulp  is  no  longer  of 
any  use,   and    may,  without   damage,    be    dispensed 


288  EXPOSED    PULPS. 

with;  while  others  maintain  that  when  the  pulp  is 
destroyed  the  tooth  is  no  longer  of  any  value.  The 
truth  is.  perhaps,  a  medium  between  these  extremes. 
The  pulp  of  the  tooth  is  valuable  in  the  economy,  or 
nature  would  dispense  with  it.  Analogy  teaches  that 
it  would  not  be  retained  longer  than  it  could  serve 
some  beneficial  purpose.  But  it  is  also  true  that  a 
tooth  may  be  retained  and  perform  its  proper  Junc- 
tion for  a  long  time  after  the  destruction  of  its  pulp, 
notwithstanding  it  is  in  a  less  perfect  condition; 
though  it  is  always  desirable  to  preserve  the  life  of 
the  tooth  when  practicable,  for  the  crown  depends  on 
the  pulp  for  its  vitality,  and  living  dentine  presents 
more  resistance  to  decay  than  dead;  besides,  a  dead 
tooth  never  exhibits  the  bright,  life-like  appearance 
of  a  living  one.  The  parts  about  a  dead  tooth,  too, 
are  far  more  liable  to  disease  than  those  about  a  liv- 
ing one.  These  are  a  few  of  the  considerations  for 
retaining  the  pulps  of  the  teeth. 

It  has  been  maintained  that  the  structure  of  the 
tooth-pulp  is  of  such  peculiar  character,  and  so  sus- 
ceptible of  diseased  action  that  after  it  has  become 
affected,  though  but  slightly,  it  cannot  be  restored  to 
a  healthy  condition.  We  see  no  ground,  however, 
for  such  an  assumption,  except  it  be  in  the  imperfect 
treatment  which  this  organ  so  frequently  receives; 
for  the  fact  of  its  delicate  structure  does  not  neces- 
sarily imply  an  impossibility  of  restoring  it  from  dis- 


TREATMENT    OF    EXPOSED    PULPS.  289 

ease.  The  pulp  of  the  tooth  is  endowed  with  such 
functions  as  ordinarily  render  living  tissues  suscep- 
tible of  treatment  for  abnormal  conditions,  such  as 
circulation,  nutrition,  absorption^  and  a  distribution 
of  nerves.  The  success  attending  the  methods  of 
treating  exposed  pulps  practiced  by  the  dental  pro- 
fession daring  the  last  few  years  is  a  source  of  more 
encouragement  than  a  thousand  theories. 

Treatment  of  Exposed  Palps. — In  cases  where  the 
conditions  are  favorable, — the  constitution  good,  the 
pulp  but  recently  exposed  at  a  small  orifice,  and  in 
a  healthy  condition, — treatment  may  be  instituted 
with  almost  absolute  certainty  of  success.  If  there 
is  no  inflammation  or  irritation,  therapeutic  treat- 
ment is  not  indicated;  but  the  decay  should  be  re- 
moved and  the  cavity  formed  without  wounding  the 
pulp,  if  possible:  though  a  slight  wound  is  of  no 
serious  consequence,  for  immediately  after  the  hem- 
orrhage ceases  the  operation  may  proceed  as  though 
the  pulp  were  intact.  There  have  been  suggested 
various  methods  for  protecting  the  pulp  in  cases  of 
this  kind;  formerly  the  capping  of  pulps  was  exten- 
sively practiced,  by  which  a  shield  was  thrown  over 
the  exposed  point,  so  as  to  prevent  the  filling  from 
coming  in  contact  with  it.  Various  materials  have 
been  su^ested  and  used  for  caps,  but  gold  and  lead 
were  formerly  used  for  this  purpose,  especially  when 
l  he  object  was  to  form  an  arch  over  the  point  of  ex- 

l'j 


290  EXPOSED    PULPS. 

posure.  These  caps  are  cut  oui  of  thin  gold  plate,  or 
thick  sheet-lead,  of  the  proper  shape  and  size,  and 
stamped  with  a  convex  punch,  thus  receiving  such  a 
concavity  as  fits  them  for  covering  the  exposed  pulp 
without  touching  it.  A  little  groove,  of  depth  suffi- 
cient to  hold  the  cap,  and  prevent  it  from  being  dis- 
placed by  the  introduction  of  the  filling,  may  be  made 
in  the  dentine  all  round  the  orifice  of  exposure.  The 
cap  is  then  to  be  adjusted  to  its  position  in  the 
cavity,  having  been  previously  touched  round  its 
edge  with  adhesive  wax;  the  filling  is  then  intro- 
duced in  the  usual  manner,  carefully,  so  as  not  to 
displace  the  cap  ;  and.  if  this  is  of  lead,  great  caution 
is  to  be  observed  in  condensing  the  filling  above  it 
since  it  will  be  easily  compressed. 

The  therapeutic  influences  of  lead  on  exposed 
pulps  is  supposed  by  some  to  be  definite  and  decided; 
but,  though  lead  is  a  less  perfect  conductor  of  heat, 
and,  in  this  respect,  is  better  than  gold,  and  though 
in  the  capacity  of  a  pulp-cap  its  indestructibility  is 
probably  quite  sufficient,  yet,  if  no  change  takes  place 
in  it,  it  is  not  very  apparent  how  it  exercises  any 
therapeutic  action  on  the  pulp.  Experience,  how- 
ever, proves  that  the  success  is  quite  as  good  in  the 
use  of  lead  caps  as  in  those  of  gold,  and  the  former 
are  more  easily  applied. 

Another  method  of  shielding  an  exposed  pulp  is, 
to  form  an  arch  over  it  by  the  filling.     This  operation 


TREATMENT    OF    EXPOSED    PULPS.  291 

is  performed  by  beginning  the  filling  at  that  side  of 
the  cavity  most  easily  approached,  building  on  the 
gold  from  the  points  of  its  attachment  almost  to  the 
point  at  which  the  pulp  is  exposed,  and  then  attach- 
ing from  one  point  to  another  without  permitting  the 
gold  to  come  in  contact  with  the  pulp.  Care  should 
be  taken  that  the  gold  present  as  smooth  a  surface  to 
the  pulp  as  possible.  When  the  orifice  of  exposure 
has  been  well  covered  and  protected,  the  remaining 
portion  of  the  cavity  is  filled  as  usual.  This  method 
of  forming  a  protection  over  a  tooth-pulp  possesses  no 
advantage  over  the  ordinary  cap ;  and  being  much 
more  difficult,  it  is  impracticable  in  any  but  skilful 
hands. 

This  practice  with  exposed  pulps,  however,  has 
within  the  last  few  years  been  almost  wholly  aban- 
doned, for  the  following  reasons:  because  it  so  fre- 
quently failed  to  accomplish  the  object,  and  because 
a  better  method  of  treatment  has  been  discovered. 
It  was  found  that,  under  that  practice,  many  cases 
which  at  first  promised  well  did  not  preserve  the  life 
of  the  pulp,  though  the  fatal  results  were  not  always 
immediate — a  year  or  two,  and  in  some  instances  a 
much  longer  period,  intervening  between  the  opera- 
tion and  the  death  of  the  tooth.  In  favorable  cases, 
the  pulp,  even  alter  exposure,  will,  if  protected  from 
tli<-  influence  of  foreign  substances,  throw  out  a  bony 
deposit,  and   even   close  up  an   orifice  of  exposure, 


292  EXPOSED    PULPS. 

thus  forming  for  itself  a  natural  shield.  Tt  is  sug- 
gested that  the  capping  operation  is  not  the  best  pro- 
tection for  facilitating  this  process.  It  is  probable 
that  in  some  cases  the  space  between  the  cap  and  the 
pulp,  though  it  were  large,  would  be  filled  with  lymph; 
and  even  if  it  were  thus  filled,  a  bony  deposit  might 
not  be  made;  and  if  it  were  not,  it  could  not  fail  ul- 
timately to  prove  injurious  to  the  pulp.  But  if  the 
space  should  not  be  filled  with  lymph,  the  difficulty 
would  be  equally  as  great,  since  the  pulp  would  pro- 
trude through  the  vacuum  beneath  the  cap,  and  nec- 
essarily become  diseased,  since  it  would  be  irritated 
by  its  contact  with,  and  its  pressure  against,  the  sharp 
edges  of  dentine  at  the  orifice  of  the  cavity  ;  and  it 
may  remain  thus  diseased  for  a  long  time,  or  die  at 
once.  Thus  it  is,  no  doubt,  that  the  great  majority 
of  failures  occur  under  this  kind  of  treatment.  In 
order  to  obviate  this  difficulty,  it  has  been  suggested 
that  the  space  under  the  cap  be  filled  with  some  ap- 
propriate substance,  as  a  thick  solution  of  gutta-percha 
and  chloroform,  or  a  small  pledget  of  cotton  saturated 
with  collodion. 

The  frequent  failures  whieh  occur  in  capping  pulps 
have  incited  the  profession  to  seek  some  other  method 
of  treatment.  A  vacuum  above  the  pulp  being  ob- 
jectionable, some  suitable  material  is  employed  as  a 
shield  for  this,  being  placed  on  the  orifice  of  expos- 
ure, in  contact  with  the  pulp ;  and  the  filling  is  then 


TREATMENT   OF    EXPOSED    PULPS.  293 

introduced  without  pressure  upon  the  point  of  expos- 
ure. There  are  several  substances  that  have  been 
thus  employed,  the  chief  of  which  are  asbestos,  oiled 
silk,  collodion,  gutta-percha,  Hill's  stopping,  and  os 
artificial.  The  material  for  this  purpose  should  be  a 
non-conductor  of  heat,  should  not  be  subject  to  de- 
composition when  in  contact  with  the  pulp,  should  be 
non-irritant  and  should  present  a  smooth  surface  and 
be  easily  adapted.  In  shielding  the  pulp  in  this 
manner,  it  is  important  that  pressure  be  not  made 
upon  it ;  and  there  is  not  much  liability  to  this,  where 
the  orifice  of  exposure  is  small,  but  where  it  is  large, 
much  care  is  required  in  the  introduction  and  con- 
solidation of  the  plug.  The  opinion  has  been  enter- 
tained by  some  that  the  pulp  of  a  tooth  will  not  tol- 
erate any  foreign  substance  in  contact  with  it;  but 
facts  refute  such  an  opinion.  By  this  kind  of  protec- 
tion for  a  pulp,  secondary  dentine  is  more  likely  to 
be  developed. 

A  very  efficient  covering  for  an  exposed  pulp  may 
be  made  by  dropping  on  it  a  little  collodion  or  solu- 
tion of  gutta-percha,  and  after  the  evaporation  of  the 
ether  or  chloroform  filling  over  it.  This  method  has 
the  advantage  of  completely  filling  and  occupying  the 
space,  and  exactly  conforming  to  the  part,  which  is 
an  important  requisite  in  this  operation.  .When  the 
exposure  is  at  a  large  orifice,  if  the  pulp  is  healthy, 
and  the   constitution   of  the   patient  good,  the  same 


29  I  EXPOSED    PI   I.I-. 

general  course  of  treatment  may  be  adopted,  except 
thai  more  cai-e  and  skill  will  be  necessary  in  the 
performance  of  an  operation,  [ndeed,  it  is  difficult 
to  make  a  good  operation  in  cases  of  this  kind,  using 
for  the  covering  only  a  soft  or  flexible  material. 

A  method  of  operating  that  is  probably  more  effi- 
cient than  those  already  mentioned,  is  to  prepare  the 
cavity  as  described,  place  on  the  pulp  two  or  three 
drops  of  collodion  or  solution  of  gutta-percha,  letting 
it  partially  stiffen,  and  then  over  this  lit  a  gold  or 
lead  cap  as  exactly  as  possible,  so  that  it  shall  rest 
on  the  solid  dentine,  far  enough  from  the  orifice  of 
exposure  to  preclude  it  from  injurious  influence  on 
the  pulp.  On  this,  the  filling  is  introduced  as  usual, 
care  being  had  not  to  displace  the  cap.  which  in  all 
cases  should  have  a  seat  made  lor  it,  formed  at  the 
time  of  the  preparation  of  the  cavity. 

When  the  pulp  of  a  tooth  becomes,  by  exposure, 
inflamed  or  diseased,  some  more  special  treatment  is 
indicated,  and  usually  it  is  therapeutic.  In  every 
such  case,  the  treatment  will  contemplate  either  the 
preservation  of  the  pulp,  when  the  circumstances 
will  warrant ;  or  when  they  will  not,  then  its  destruc- 
tion and  removal.  The  former  of  course  is  always  to 
be  preferred,  where  practicable.  Some  of  our  best 
operators  very  strongly  denounce  the  wholesale  de- 
struction of  the  pulps  of  the  teeth,  practiced  by  many; 
while  some  dentists  never  attempt  to  restore  and  pre- 


TREATMENT  OF  EXPOSED  PULPS.  295 

serve  them  at  all,  however  slightly  diseased.  This, 
as  elsewhere  intimated,  is  an  erroneous  practice ;  for 
there  is  no  obvious  reason  why  the  pulp  of  a  tooth 
may  not  be  restored  from  disease  to  health  as  readily 
as  other  parts,  endowed  as  it  is  with  circulation,  nu- 
trition, absorption  and  the  distribution  of  nerves. 
The  particular  kind  of  treatment  required  in  any 
given  case,  however,  will  be  controlled  by  various 
circumstances,  such  as  the  susceptibility  of  the  case, 
the  nature  and  extent  of  the  disease,  whether  it  is  of 
chronic  or  acute  type.  When  the  irritation  or  inflam- 
mation is  but  slight,  and  is  kept  up  solely  by  the  con- 
tact of  irritating  substances,  restoration  of  the  pulp 
may  be  effected  by  a  removal  of  these  irritating 
causes,  and  protection  of  the  pulp  against  their  fur- 
ther influence  :  in  such  case,  nature,  unaided,  effects 
the  restoration.  In  a  feeble  constitution,  the  pulp, 
though  but  slightly  affected,  will  require  topical  thera- 
peutic treatment;  and  meanwhile  general  treatment 
may  be  employed  to  give  increased  tone  to  the  sys- 
tem. In  the  local  treatment,  neutralizing  agents 
should  be  applied  first,  and  afterwards  such  as  will 
counteract  and  reduce  inflammation,  especially  if  this 
is  in  an  active  state.  But  if  the  pulp  is  in  a  morbid 
condition,  with  retarded  circulation  and  a  tendency 
to  enlargement,  active  and  stimulating  applications 
will  be  indicated,  and  in  some  cases  eecharotics,  such 
as  nitrate  of  silver,  chloride  of  zinc,  and  chromic  acid, 


29G  EXPOSED   PULP8. 

the  latter  especially  where  there  is  a  tendency  to  pru- 
rient enlargement  of  the  pulp.  The  therapeutic  prin- 
ciples embraced  in  astringents,  tonics,  stimulants,  and 
escharotics,  are  mainly  to  be  relied  upon  in  the  topi- 
cal treatment  of  exposed  pulp. 

The  length  of  time  requisite  for  this  treatment  will 
vary  with  different  cases.  In  the  case  of  a  recent 
acute  inflammation,  the  process  of  restoration  may  be 
completed  in  two  or  three  days  ;  while  in  other  cases, 
where  the  difficulty  is  of  long  standing  and  of  a  more 
complex  character,  it  will  require  from  a  week  to  two 
months.  The  systemic  condition  of  the  patient  also 
exercises  a  great  modifying  influence  upon  the  treat- 
ment. Leeching  and  counter-irritation  of  the  gums 
are  sometimes  resorted  to  in  this  treatment ;  but  it 
is  rare  that  any  definite  beneficial  result  ensues.  De- 
pletion of  the  pulp  itself  may  often  be  practiced 
with  decided  success;  and  it  may  be  accomplished 
either  by  puncturing  the  pulp  with  a  fine-pointed  in- 
strument, or  by  excising  a  small  portion  of  it  at  the 
orifice  of  exposure,  in  either  case  avoiding  laceration. 
By  this  means  the  distended  vessels  are  relieved  ; 
and  in  many  cases,  where  the  difficulty  is  but  slight, 
immediately  after  such  relief  by  puncturing,  so  soon 
as  the  ha3morrhage  has  ceased,  the  tooth  may  be 
filled.  But  if  the  depletion  is  by  excision,  time  must 
be  allowed  for  the  recovery  of  the  incised  surface — 
ordinarily  from  three  to  ten  days. 


TREATMENT   OF    EXPOSED    PULPS.  297 

A  method  of  treatment  of  exposed  pulps — first 
introduced  to  the  notice  of  the  profession  by  Dr. 
Allport,  and  one  which  in  his  hands  has  proved  quite 
successful — consists  in  the  excision  of  a  portion  of 
the  pulp  at  the  orifice  of  exposure,  drawing  the 
edges  of  the  incised  part  together,  and  inducing  their 
union,  and  in  this  manner  closing  the  wound,  when 
less  space  is  occupied  by  the  pulp  than  before  the 
operation.  After  securing  this  result,  the  operation 
of  filling  the  tooth  may  be  performed ;  the  same  care 
being  observed,  however,  as  already  suggested  in 
cases  of  exposed  pulp. 

The  employment  of  pepsin  has  been  quite  effective 
in  the  hands  of  some  practitioners.  The  method  of 
application  is  as  follows  :  with  the  pure  pepsin  in 
powder,  and  diluted  hydrochloric  acid,  or  liquid  pep- 
sin, form  a  paste  of  creamy  consistence,  that  can  be 
readily  applied  to  an  exposed  pulp. 

The  cases  in  which  this  preparation  seems  appro- 
priate and  efficient  are  those  in  which  there  is  debris 
and  offensive  matter  in  contact  with  and  irritating 
the  pulp  that  cannot  be  readily  removed,  either  with 
an  instrument  or  by  washing.  There  is  often  a  film 
of  partially  devitalized  pulp-substance  upon  and  cov- 
ering the  exposed  part,  that  operates  as  an  active 
irritant  to  the  tissue  beneath  it;  this  and  all  similar 
substances  are  dissolved  and  removed  by  the  action 
of  the   pepsin   paste  ;  and   not   only   is  this   accom- 


298  EXPOSED   PUT. I'-. 

plished,  but  the  pulp  is  stimulated  to  a  healthy  ac- 
tion. 

For  the  application  the  cavity  through  which  the 
exposure  is  effected  should  be  cleaned  thoroughly  and 
dried  ;  then  place  a  drop  of  the  paste  on  the  point  of 
exposure,  on  this  put  two  or  three  plies  of  bibulous 
paper,  then  fill  the  cavity  with  wax,  softened  by 
heat,  so  that  its  introduction  will  not  cause  pressure 
upon  the  pulp.  This  should  remain  for  from  six 
to  twenty-four  hours,  when  it  should  be  removed ; 
the  pulp  will  usually  now  present,  at  the  orifice  of 
exposure,  the  bright  pinkish  hue  of  the  healthy 
tissue  ;  very  seldom  will  a  second  application  be  re- 
quired. 

This  condition  being  attained,  the  pulp  is  ready 
for  its  covering  for  permanent  protection. 

For  the  proper  covering  and  filling  over  an  ex- 
posed pulp,  certain  indications  must  be  fulfilled. 

First.  A  material  must  be  used  that  will  be  ac- 
ceptable to  the  tissue,  that  will  in  no  degree  irri- 
tate it. 

Second.  It  should  be  a  substance  that  will  not  de- 
compose or  undergo  change  when  in  contact  with  the 
pulp. 

Third.  It  must  be  a  material  of  such  consistence 
as  to  be  made  easily  to  occupy  all  the  space  at  the  ori- 
fice of  exposure,  and  yet  make  no  pressure  upon  the 
pulp. 


TREATMENT   OF    EXPOSED    PULPS.  299 

Fourth.  It  should  be  a  non-conductor  of  heat  equal 
at  least  to  the  dentine. 

Fifth.  It  should  possess  sufficient  resistance  to 
admit  the  proper  introduction  of  the  best  material 
for  filling. 

Thus  it  is  apparent  that  the  aim  is,  and  should  be, 
to  place  the  exposed  pulp  again  in  as  nearly  its  nor- 
mal state  of  closure  as  possible.  This  is  the  criterion 
that  should  guide  in  the  performance  of  this  most 
delicate  operation. 

A  very  good  method  of  accomplishing  this  was 
suggested  by  Dr.  J.  S.  King  about  the  year  1871. 
Others  have  claimed  that  they  had  used  the  same 
principle  before  ;  but  such  claim  is  not  established  ; 
certainly  he  was  the  first  to  bring  it  to  the  notice  of 
the  profession. 

It  consists  in  placing  in  the  orifice  of  exposure  and 
on  the  pulp,  after  it  has  been  freed  from  all  irritants 
and  debris,  and  restored  to  a  state  of  health  as  nearly 
as  possible,  a  paste  of  oxide  of  zinc  and  a  solution  of 
creosote  of  a  thick  cream}'  consistence  ;  with  this 
the  orifice  should  be  completely  covered ;  remove 
any  excess  of  creosote  with  bibulous  paper ;  then 
cover  this,  and  fill  the  cavity  of  decay  with  os  artifi- 
cial or  Guillois'  cement,  or  better  now,  with  oxy-phos- 
phate  of  zinc,  which  is  non-irritant.  So  far  as  the 
pulp  is  concerned,  this  is  to  be  the  permanent  cover- 
ing; as  to  the  cavity  of  decay,  this  may  constitute 


300  EXPOSED    PULPS. 

the  permanent  filling,  or  sufficient  of  the  os  artificial 
niny  be  cut  away  from  the  cavity  to  enable  it  to  be 

well  filled  with  gold,  or  any  other  material.  This  in 
the  hands  of  many  has  proved  a  very  successful 
method  of  inclosing  exposed  pulps. 

The  formation  of  secondary  dentine,  by  which  the 
orifice  of  exposure  is  closed,  has  already  been  re- 
ferred to;  and  it  has  been  suggested  that  treatment 
to  facilitate  this  process  may  be  instituted.  With  a 
view  to  this,  temporary  fillings  are  sometimes  intro- 
duced. If  a  shield  of  secondary  dentine  is  desirable 
before  permanent  filling,  the  best  method  of  securing 
it  is,  after  seeing  that  the  general  recuperative  power 
is  in  the  best  condition,  to  place  in  the  cavity  a  tem- 
porary filling,  of  such  material  and  in  such  manner 
as  will  be  most  acceptable  to  the  pulp,  and  then  leave 
nature  to  accomplish  the  work.  In  many  cases,  es- 
pecially in  young  persons,  this  process  would  be  fa- 
cilitated by  an  administration  of  bone  phosphate. 
The  pulps  of  the  teeth  of  the  young  are  more  diffi- 
cult to  treat  successfully  than  those  of  the  more  ad- 
vanced in  life. 

A  method  of  treating  exposed  pulps  with  a  view 
of  securing  a  closure  of  the  orifice  of  exposure  by  na- 
ture, was  first  suggested  and  practiced  in  1873,  by 
Dr.  J.  E.  Cravens,  and  consisted  of  the  following 
treatment: 

The  exposed  pulp   should  be  rendered  as  nearly 


TREATMENT   OF    EXPOSED    PULP3.  301 

absolutely  free  from  extraneous  matter  as  possible, 
but  softened  or  partially  decalcified  dentine  may  re- 
main undisturbed  in  the  cavity.  The  cavity  should 
be  secured  against  moisture,  and  kept  so  during  the 
operation;  being  thoroughly  clean  and  dry,  the  pulp 
exposure  should  be  covered  with  a  paste  prepared  as 
follows:  Upon  a  warm  slab  of  ground  glass  put  a 
drop  of  Merck's  lactic  acid;  add  twice  that  volume 
of  magma,  or  freshly  precipitated  phosphate  of  lime; 
then  rub  till  a  complete  solution  is  effected.  This 
is  lacto-phosphate  of  lime.  To  this  solution  add  dry 
phosphate  of  lime  until  the  paste  is  of  proper  consist- 
ence for  application.  Place  this  paste  directly  on  the 
exposed  pulp  so  as  to  occupy  all  the  space  and  yet 
make  no  pressure  upon  it;  the  cavity  may  be  filled 
from  one-fourth  to  one-third  full  of  this  material; 
then  remove  the  moisture  from  the  surface  of  the 
paste  with  spunk,  or  some  absorbent,  then  cover  it 
with  two  or  three  plies  of  bibulous  paper,  cut  to  fit 
the  cavity  and  moisten  with  sweet  oil;  press  this 
carefully  upon  the  paste,  especially  all  round  the 
border;  then  cover  this  and  fill  the  cavity  with  os 
artificial,  or  its  equivalent.  Hill's  stopping  or  gutta- 
percha cannot  with  safety  be  used  instead  of  the  os 
artificial,  as  more  or  less  pressure  would  be  occasioned 
by  their  introduction.  Dr.  Cravens  suggests  that 
tin-  pulp  should  not  be  treated  previously  with  any- 
thing  that    would   coagulate    albumen,   and,    indeed, 


302  EXPOSED   PULPS. 

should  have  no  preparatory  treatment  except  that 
already  referred  to. 

This  dressing  and  filling  should  remain  undis- 
turbed for  from  two  to  six  weeks,  and  one  application 
is  usually  quite  sufficient  to  induce  bony  deposit  to 
fill  the  orifice  of  exposure  and  cover  the  pulp. 

Pain  will  seldom  be  experienced  after  the  applica- 
tion of  the  phosphate  of  lime  as  above  described, 
but  if  it  should  the  use  of  sedative  treatment,  either 
locally  or  through  the  system,  will  meet  the  diffi- 
culty. In  no  case  should  the  dressing  and  filling  be  re- 
moved or  disturbed  till  the  allotted  time  has  elapsed. 
Dr.  Cravens  entertains  the  opinion  that  the  phosphate 
of  lime,  thus  applied,  is  appropriated  in  the  forma- 
tion of  the  new  deposit,  and  that  thus  the  living 
tissue  beneath  has  co-operation  in  this  process,  at 
least  so  far  as  supply  is  concerned. 

Destruction  of  the  Pulp. — There  are  cases  in  which 
an  attempt  to  restore  the  pulp,  even  when  recently 
and  but  slightly  diseased,  would  prove  unavailing; 
so  feeble  is  the  vitality  that  it  is  destroyed  at  almost 
the  first  touch.  Two  cases  in  apparently  the  same 
condition  pathologically,  but  in  different  constitu- 
tions, will,  under  the  same  treatment,  exhibit  very 
different  results.  A  pulp  in  a  sj'stem  with  low  vital 
power,  that  is  highly  diseased,  is  but  seldom,  if  ever, 
under  any  circumstances,  susceptible  of  restoration ; 
and  in  such   case  of  course,   devitalization    and    re- 


REMOVAL   OF    PULPS.  303 

moval  are  indicated.  This  was  formerly  supposed  to 
be  an  impracticable  operation,  for  two  reasons:  first, 
because  it  was  very  difficult  and  painful;  and  second, 
because  of  the  consequences  likely  to  ensue.  Then, 
the  operation  was  attempted  only  on  teeth  having 
one  root,  and  those  of  cylindrical  form;  but  now,  it 
is  performed  successfully  on  all  classes  of  teeth.  When 
destruction  of  the  pulp  is  decided  upon,  such  means 
should  be  employed  as  will  effect  the  object  promptly 
and  thoroughly.  Everything  should  be  entirely  re- 
moved from  the  pulp-chamber  and  the  canal  of  the 
root,  for  any  remaining  portion  is  liable  to  induce  in- 
flammation and  suppuration;  and  alveolar  abscess 
also  frequently  ensues. 

There  are  two  methods  of  destroying  the  pulp; 
the  one  by  an  operation;  the  other  by  the  applica- 
tion of  some  devitalizing  agent.  The  choice  of  these 
methods  will  be  governed  by  circumstances,  such  as 
the  temperament  of  the  patient,  the  condition  of  the 
tooth  and  parts  about  it,  and  the  class  of  the  tooth 
to  be  operated  upon.  For  patients  of  a  nervous,  ir- 
ritable temperament,  to  whom  a  removal  of  the  pulp 
by  an  operation  would  occasion  great  pain  and  a  se- 
vere shock,  it  would  be  better  to  apply  some  agent  to 
destroy  the  vitality  of  the  pulp,  and  then  remove  it; 
but,  on  the  contrary,  where  there  is  vigor,  and  a  ca- 
pacity of  endurance,  it  is  preferable  to  remove  the 
pul j»  at  once  by  an  operation.     To  accomplish  this, 


304  EXPOSED    PULPS. 

there  are  two  or  three  methods  of  manipulation.  In 
the  first  place,  however,  by  whatever  method  it  is 
removed,  it  should  be  fully  exposed;  the  orifice  of  ex- 
posure should  be  as  large  as  the  pulp-chamber,  and 
the  entrance  as  nearly  as  possible  on  a  line  with  the 
tooth's  axis;  hence  it  will  be  necessary,  in  many 
cases,  to  make  an  opening  into  the  pulp-chamber  at 
a  point  different  from  that  of  the  opening  produced 
by  the  decay.  For  instance,  in  the  incisor  teeth, 
when  the  decayed  cavity  is  small,  on  the  side  near 
the  margin  of  the  gum,  penetrating  to  the  pulp-cham- 
ber, and  exposing  the  pulp,  the  entrance  through 
this  opening  into  the  canal  will  be  almost  at  right 
angles  with  it;  and  in  such  case  it  would  be  impos- 
sible, through  this  opening,  to  manipulate  freely  in 
the  root,  and  it  would  be  necessary  to  make  an  open- 
ing with  a  drill  through  the  palatal  portion  of  the 
tooth  directly  into  the  canal  and  on  a  line  with  it, 
which  opening  should  be  large  enough  readily  to  al- 
low of  a  removal  of  the  pulp  through  it,  and  of  an 
unimpeded  performance  of  all  the  subsequent  opera- 
tions in  the  canal  of  the  root. 

After  the  pulp  has  been  exposed  by  the  proper 
opening,  the  instrument  should  be  selected  for  its  re- 
moval. There  are  different  forms  of  instruments  for 
this  purpose.  Some  operators  employ  the  untem- 
pered,  four-sided,  barbed  broach,  thrusting  it  into 
the  canal  as  far  as  possible,  then  turning  it  two  or 


REMOVAL   OF   PULPS.  305 

three  times  around,  and  thus  wrapping  the  pulp  round 
the  instrument,  when  both  are  drawn  away  together. 
This  method  always  occasions  considerable  pain. 
Others  employ  simply  the  three  or  four-sided  broach, 
thrusting  it  through  the  pulp  all  the  way  up  the 
canal,  and  thus  lacerating  it  and  breaking  up  its 
structure,  so  that  it  may  afterward  be  removed  with- 
out much  pain.  Another  method  and  one  which 
seems  preferable  to  all  the  others,  is  as  follows  : 
Take  a  very  fine  un tempered  steel  wire,  round  and 
smooth,  not  larger  than  34  to  36  of  Stub's  gauge- 
plate  ;  flatten  the  extreme  point,  and  turn  it  to  an 
angle  of  from  thirty  to  forty  degrees ;  place  the  edge 
of  this  against  one  wall  of  the  canal  at  the  point  of 
exposure  of  the  pulp  ;  press  it  steadily  up  the  canal, 
with  its  edge  bearing  against  the  wall  as  far  as  it  will 
go,  and  then  twirl  it  suddenly  round.  Thus  an  ex- 
cision is  effected  near  the  point  of  the  root,  when  the 
pulp  with  the  instrument  may  be  drawn  away  to- 
gether ;  or,  if  not  thus  removed,  it  may  be  caught  with 
some  fine  point,  and  removed  with  little  or  no  pain. 
This  manner  of  introducing  the  instrument,  too, 
causes  less  pain  than  either  of  the  others,  for  there 
are  no  sharp  edges  or  points  presented  in  passing  the 
instrument  up  the  canal,  to  cut  or  lacerate  the  pulp. 
In  the  removal  of  the  pulp  from  the  teeth  of  young 
persons,  care  should  be  taken  lest  the  instrument 
pass   entirely   through   the    foramen,  at   the   apex  of 

20 


306  EXPOSED    PULPS. 

the  root;  but  with  adults  there  is  little  or  no  danger 
of  such  an  accident. 

The  directions  here  given  would  be  quite  sufficient, 
if  closely  followed,  for  the  removal  of  the  pulps  of 
the  six  anterior  superior  teeth.  For  the  removal  of 
the  pulps  from  the  bicuspids,  the  entrance  can  ordi- 
narily be  effected  through  the  decayed  cavity.  Usu- 
ally there  is  some  lateral  compression  of  the  roots  of 
these  teeth  ;  and  the  canal  through  the  root  corre- 
sponds in  its  formation,  so  that  it  presents  a  mere 
fissure,  expanded  a  little  on  each  side  of  the  centre. 
It  is  often  difficult,  and  requires  very  delicate  manip- 
ulation, to  remove  all  the  pulp  from  these  fissures. 
A  very  fine  instrument  may  be  pressed  down  each 
side,  and  yet  a  portion  of  the  pulp  remain  in  the 
centre.  This  difficulty  is  most  fully  presented  in 
those  cases  in  which  there  has  been  an  apparent, 
though  abortive,  effort  of  nature  to  produce  two 
roots. 

The  removal  of  the  pulps  of  the  molar  teeth  is  a 
more  extensive  and  complicated  operation.  The  pulp 
to  be  operated  upon  should  be  fully  exposed,  the  ori- 
fice of  exposure  being  made  as  nearly  as  possible  of 
the  size  of  the  pulp-chamber ;  and  the  instrument  to 
be  used  should  be  such  as  last  described,  except  that 
it  should  be  much  larger,  and  is  to  be  introduced,  in 
the  same  manner,  to  the  bottom  of  the  pulp-chamber, 
and  rotated  suddenly,  so  as  to  cut  off  the  ramifica- 


REMOVAL   OF    PULPS.  307 

tions  of  the  pulp  into  the  roots,  thus  at  one  sweep 
dislodging  the  entire  body  of  it  without  laceration. 
The  practice  of  plunging  a  large  barbed  or  cutting 
instrument  into  the  pulp  of  a  molar  tooth  is  painful 
in  the  extreme. 

The  pain  of  removing  the  living  tooth-pulp  may  be 
much  mitigated  in  all  cases,  and  in  many  prevented 
altogether,  by  the  use  of  local  anaesthesia.  This  may 
be  effected  by  the  application  of  chloroform,  or  some 
one  of  the  various  anaesthetics  that  are  available,  di- 
rectly to  the  pulp.  The  application  of  cold  is  quite 
efficient ;  this  may  be  effected  by  the  use  of  ether 
spray  or  ice.  So  extended  have  become  the  facilities 
for  inducing  local  anesthesia,  that  the  spray  or  ice 
need  hardly  be  employed. 

The  branches  of  the  pulp  in  the  roots  should  be 
removed  in  the  manner  already  directed  for  the  re- 
moval of  the  pulps  from  teeth  of  single  roots.  The 
palatal  root  is  very  easily  operated  upon;  but  as  to 
the  buccal  roots,  there  is  frequently  encountered  the 
same  difficulty  referred  to  in  speaking  of  the  bicus- 
pids. When  a  pulp  is  removed  in  this  manner,  the 
wound  commonly  heals  by  first  intention,  and  there 
is  formed  a  permanent  cicatrix. 

Actual  Cautery.— For  destroying  tooth-pulp,  the 
actual  cautery  was  formerly  employed  to  a  consider- 
able extent,  and  was  at  one  time  a  favorite  method 
with    French    dentists.      This   consists  in    heating  a 


308  EXPOSED   PULPS. 

wire  of  proper  size  to  a  white' heat,  and  thrusting  it 
into  the  canal  of  the  root  to  the  apex,  the  object  be- 
ing to  destroy  the  pulp  the  instant  the  wire  comes 
in  contact  with  it.  The  operation  requires  much 
skill,  and  is  attended  with  many  difficulties.  It  is 
fraught  with  terror  to  the  patient ;  if  the  temperature 
of  the  wire  is  not  at  white  heat  at  the  time  of  its  in- 
sertion, the  pain  of  the  operation  is  most  intense ; 
it  is  liable  to  leave  the  parts  in  such  a  condition  as 
often  to  induce  inflammation  and  suppuration,  which 
may  involve  the  investing  membrane  and  the  sur- 
rounding parts.  Besides,  by  this  method,  the  object 
is,  at  best,  no  more  successfully  attained  than  by 
others. 

The  galvanic  cautery  has  been  employed  to  some 
extent  in  general  surgery,  and  it  is  very  probably  the 
best  form  in  which  the  actual  cautery  can  be  applied 
for  destroying  pulps  of  teeth. 

Potential  Cautery. — This  term  is  applied  to  those 
therapeutic  agents  which  destroy  vital  tissue  by  es- 
tablishing a  condition  incompatible  with  vitality. 
Many  preparations  have  been  employed  as  topical 
applications  to  devitalize  the  pulps  of  teeth,  but  only 
two  or  three  to  any  considerable  extent.  A  consid- 
eration of  the  nature  and  something  of  the  specific 
action  of  these  agents  may  not  here  be  out  of  place. 
And  first,  of 

Armenians  Acid. — This  has  been  more  used,  topically, 


REMOVAL   OF    PULPS.  309 

for  the  destruction  of  tooth-pulp  than  all  other  appli- 
cations. The  first  account  we  have  of  its  use  for  this 
purpose  dates  back  to  1836,  when  it  was  applied  by 
Dr.  Spooner,  though  others  claim  to  have  employed 
it  about  the  same  time.  The  specific  action  of  arseni- 
ous  acid  on  vital  tissue  is  not  well  understood.  It 
is  supposed  by  some  that  it  forms  a  compound  with 
some  element  of  the  tissue,  and  in  this  way  destroys 
the  vitality. 

Any  such  combination,  however,  has  hitherto  es- 
caped detection  ;  and  it  is  certain  that  if  a  compound 
is  formed,  it  is  not  fixed  or  permanent  in  its  charac- 
ter, since  the  arsenic  will  be  carried  to  different  parts 
of  the  system,  and  its  specific  influence  manifested 
wherever  it  goes,  which  could  not  be  the  case  if  it 
formed  a  fixed  compound.  The  more  probable  the- 
ory is  that  it  destroys  vitality  by  its  influence  on 
nerve  tissue,  producing  such  a  change  in  its  structure 
as  to  arrest  its  function  at  once.  In  reference  to  the 
action  of  this  agent  upon  living  tissue,  much  investi- 
gation remains  to  be  made.  Animal  tissue  takes  it 
up  by  imbibition  ;  and  it  is  also  absorbed  by  the  cir- 
culation, and  conveyed  by  it,  as  already  suggested, 
throughout  the  system.  Frequently,  however,  it  is 
applied  to  living  tissue,  under  conditions  that  pre- 
vent such  absorption.  It  is  often  employed  in  the 
treatment  of  carcinoma.  In  the  application  of  arse- 
niOUfl  acid   to  the  pulps  of  teeth,   for  their  destruc- 


310  EXPOSE!)   PULPS. 

tionr  several  circumstances  are  to  be  considered,  such 
as  the  age  of  the  patient,  the  constitutional  tendency, 
the  vascularity  of  the  dentine.  Where  the  vascular- 
ity is  great,  the  utmost  caution  is  required.  The  in- 
discriminate use  of  this  agent  in  the  teeth  of  the 
young  is  attended  with  great  risk.  Some  constitu- 
tions are  peculiarly  susceptible  to  its  influence,  expe- 
riencing its  effects  even  in  remote  parts  of  the  system, 
after  its  application  only  to  the  pulp  of  a  tooth.  It 
is  soluble  in  creosote  and  most  of  the  essential  oils, 
and  to  some  extent  in  alcohol  and  water.  In  many 
eases  when  it  is  applied  to  the  pulp  of  a  tooth,  more 
or  less  disturbance  of  the  periosteum  is  exhibited  a 
short  time  after — in  some  instances  in  a  few  hours, 
and  in  others  after  several  days,  thus  giving  evidence 
that  it  has  by  some  means  come  in  contact  with  the 
periosteum.  Its  influence  on  this  will  often «be  mani- 
fested under  percussion,  in  advance  of  any  other 
symptom. 

Application. — There  are  two  or  three  methods  of 
applying  arsenious  acid  for  the  destruction  of  the 
pulps  of  teeth.  The  ordinary  arsenic  of  commerce  is 
used.  It  was  formerly  employed  very  extensively  in 
connection  with  sulphate  of  morphia,  mixed  in  equal 
parts,  and  applied  to  the  pulp  with  a  small  pledget 
of  cotton,  moistened  with  creosote  or  some  essential 
oil,  the  former  being  most  frequently  used.  Alcohol, 
ether,  or  water  may  be  employed  instead  of  creosote, 


REMOVAL   OF    PULPS.  311 

and  in  some  respects  and  in  some  cases  would  be 
preferable.  The  pledget  of  cotton,  thus  prepared,  is 
introduced  into  the  decayed  cavity,  with  the  prepa- 
ration in  contact  with  the  exposed  pulp.  Another 
pledget  of  cotton,  saturated  with  a  thick  solution  of 
gum-sandarac  and  alcohol,  or  gutta-percha  and  chloro- 
form, is  placed  over  this  in  the  cavity,  to  prevent 
the  escape  of  the  preparation,  or  the  entrance  of  mois- 
ture or  foreign  substances.  Any  preparation  may  be 
used  that  will  accomplish  these  objects.  In  the  ap- 
plication of  the  pledget,  care  must  be  exercised  lest 
too  much  pressure  be  made  on  the  pulp,  and  pain  be 
thus  produced.  In  order  to  prevent  this  pressure, 
another  method  has  been  adopted,  which  consists  in 
forming  a  cap  of  lead,  placing  it  in  the  arsenic,  in  the 
dry  state  or  with  some  suitable  solvent,  and  then  fit- 
ting it  over  the  exposed  pulp,  and  retaining  it  there 
with  a  pledget  of  cotton,  as  above,  or  with  Hill's  stop- 
ping, gutta-percha,  or  adhesive  wax.  Thus  the  prep- 
aration comes  gently  in  contact  with  the  pulp,  and 
prevents  any  pressure  on  it.  The  morphine  is  used 
for  the  purpose  of  diminishing  the  pain  which  fre- 
quently results  from  the  application  of  arsenic  only  ; 
but  its  influence  for  such  a  purpose  is  predicated  more 
on  theory  than  on  practice  ;  for  facts  prove  that,  ap- 
plied to  living  tissue,  it  produces  pain  rather  than  al- 
lays it.  Therefore  the  more  observing  and  better 
class  of  practitioners  have  discarded  it. 


312  EXPOSED   PULPS. 

Other  substances  have  been  mixed  with  arsenic, 
for  the  purpose  of  mitigating  or  altogether  relieving 
the  deleterious  consequences  so  liable  to  follow  its 
administration  ;  as,  for  instance,  pulverized  charcoal, 
which,  mixed  with  it  in  equal  parts  by  weight, 
makes  a  favorite  preparation  with  some  practitioners, 
by  whom  it  is  claimed  that  the  charcoal  counteracts 
the  specific  effect  of  the  arsenic  on  parts  other  than 
those  for  which  it  is  directly  designed.  But  this 
theory,  in  the  light  of  any  elucidation  yet  given,  is 
very  vague.  The  claim  cannot  be  that  charcoal  is 
an  antidote  to  arsenic,  since  facts  refute  it ;  for  if  it 
were,  the  arsenic  of  the  preparation,  when  applied  to 
the  pulp  of  a  tooth,  would  fail  of  its  effect,  because, 
the  charcoal  being  also  in  contact  with  the  pulp, 
would  there,  if  ever,  counteract  the  poison.  But  this 
it  does  not  do,  for  the  pulp  is  destroyed  about  as 
readily  by  this  preparation  as  by  arsenic  alone.  And 
if  when  the  arsenic  and  charcoal  are  thus  together  no 
counteracting  influence  of  the  latter  is  manifest, 
much  less  will  there  be  any  when  the  arsenic,  es- 
caped from  the  charcoal,  runs  riot  through  the  tis- 
sues, whither  the  latter  cannot  follow.  The  only 
probable  advantage,  then,  of  this  preparation  is,  that 
the  arsenic  is  not  taken  up  from  it  by  the  tissues 
so  rapidly  as  when  it  is  applied  alone,  or  with  any- 
thing that  is  soluble  with  it ;  for  when  thus  applied, 
the  whole  is  very  soon  dissolved,  and   taken  up   by 


REMOVAL  OF  PULPS.  313 

the  pulp  and  dentine.  But  when  mixed  with  char- 
coal or  the  like,  little  more  of  the  arsenic  is  absorbed 
than  that  which  comes  in  contact  with  the  pulp. 
Hence  the  conclusion  that  the  influence  of  the  char- 
coal is  mechanical,  and  not  therapeutic. 

This  preparation  is  better  applied  perfectly  dry, 
beneath  a  lead  cap,  which  should  completely  close 
the  cavity.  Any  other  material  that  would  mix  as 
readily  with  the  arsenic,  without  being  soluble,  and 
that  would  not  induce  irritation  when  in  contact  with 
the  pulp,  would  be  quite  as  good  for  this  purpose  as 
charcoal.  Irritating  gases  generated  in  a  tightly- 
closed  cavity  are  absorbed  by  charcoal. 

Cobalt,  in  which  the  active  principle  is  arsenic, 
has  been  extensively  used  for  destroying  pulps  ;  but 
it  is  in  no  respect  superior,  and  in  some  respects  it  is 
probably  inferior,  to  the  preparation  of  charcoal  and 
arsenic;  it  is  applied  in  the  same  manner. 

The  length  of  time  the  preparation  should  remain 
in  the  tooth  will  be  determined  by  the  condition  of 
the  pulp  when  it  is  applied,  the  age  of  the  patient, 
the  vascularity  of  the  dentine,  the  susceptibility  ot 
the  patient  to  the  influence  of  arsenic,  and  like  cir- 
cumstances. It  will  usually  be  from  three  to  twenty- 
four  hours.  In  some  cases  a  very  small  particle  will 
thoroughly  accomplish  the  work,  while  in  others  a 
much  larger  quantity  may  remain  in  contact  with  the 
pulp  even  for  a  much  longer  time,  without  producing 


314  EXPOSED   PULPS. 

more  than  a  superficial  result.  And  cases  occasion- 
ally occur  in  which  it  seems  almost  impossible  to 
destroy  the  vitality  of  a  pulp  with  arsenic.  A  case  is 
on  record  in  which  the  pulp  was  first  fairly  exposed 
in  a  superior  bicuspid  tooth,  the  health  and  constitu- 
tion being  good,  and  the  temperament  sangui no-lym- 
phatic;  and  arsenic  with  morphine  was  applied  to 
it,  directly,  five  times  within  ten  days,  without  pro- 
ducing any  apparent  effect;  then  an  application  of 
creosote  and  tannin  was  made  three  or  four  times 
during  as  many  days ;  afterward  the  tooth  was  tem- 
porarily filled  with  gutta-percha;  and  finally,  in  ten 
or  twelve  days,  this  filling  being  removed,  the  pulp 
appeared  in  a  perfect  state  of  preservation  and  health, 
with  all  the  indications  of  undiminished  vitality. 
Over  the  exposed  point  there  was  placed  a  non-con- 
ductor, and  upon  it  a  filling  of  gold,  and  one  year 
after,  the  tooth  presented  the  appearance  of  perfect 
life  and  health,  having  given  the  patient  no  annoy- 
ance during  the  whole  period. 

Hence,  it  is  quite  obvious  that  there  is  a  great  di- 
versity of  susceptibility  to  the  influence  of  arsenic, 
and  that  the  study  of  these  idiosyncrasies  is  both  in- 
teresting and  valuable.  The  occurrence  of  injurious 
consequences  from  the  use  of  arsenic  has  induced 
many  operators  to  abandon  it  altogether.  But  these 
injurious  results  may  occur  either  through  mal-ad- 
ministration  or  from  a  peculiar  susceptibility  to  the 


TREATING    PULP-CAVITIES.  315 

influence  of  the  drug,  and  a  superior  skill  and  a  more 
accurate  diagnosis  would  render  less  frequent  the 
characteristic  injurious  results.  After  the  desired 
result  with  arsenic  has  been  obtained,  it  has  been 
thought  that  antidotes  to  arrest  its  further  operation 
might  be  made  available.  The  hydrated  sesquioxide 
of  iron  is  one  of  the  best  antidotes  to  arsenic,  and 
has  been  used  in  the  teeth  to  counteract  its  injurious 
effects ;  but  it  is  of  no  avail  here,  the  arsenic  has 
the  start  of  it,  and,  indeed,  would  outstrip  it  with  an 
equal  start. 

From  the  foregoing,  in  regard  to  arsenic  as  an  ap- 
plication for  destroying  the  pulps  of  teeth,  the  fol- 
lowing conclusions  are  justly  deducible :  it  is,  in 
general,  very  efficient;  it  is  a  heroic  agent;  it  should, 
in  all  cases,  be  used  with  great  caution;  in  some  cases 
it  is  entirely  inadmissible;  a  free  administration  of 
it  is  liable  to  be  followed  by  bad  consequences;  and 
skill  and  care,  rather  than  counteracting  agents,  are 
to  be  relied  upon  in  its  application. 

Filling  Pulp  Cavities  and  Canals. — After  the  pulp 
of  a  tooth  has  been  destroyed,  whether  by  an  opera- 
tion or  by  an  escharotic,  the  part  at  the  point  of  its 
detachment  should,  in  most  cases,  before  the  filling  is 
introduced,  be  rendered  healthy;  if  possible,  a  per- 
manent cicatrice  should  be  formed.  In  cases,  how- 
ever,  of  good  constitution  and  strong  recuperative 
power,  where  a  pulp  has  been  removed  by  an  opera- 


316  PULP-<  AVI'J  II  -. 

tion,  the  root  ma\  be  filled  as  soon  as  the  haemorrhage 
has  ceased;  bui  such  cases  rarely  occur.  Generally, 
the  part  will  require  treatment,  and  the  character 
and  duration  of  this  will  be  determined  by  circum- 
stances— as,  tin'  vital  energy  of  the  system,  and  the 
method  employed  for  the  pulp's  destruction.  When 
this  lias  been  effected  by  an  operation,  the  wound 
produced  by  an  excision  is  restored  to  soundness 
much  more  readily  than  when  by  an  application  of 
arsenious  acid,  and  less  topical  treatment  will  ordi- 
narily be  required,  indeed,  in  many  such  cases,  there 
will  be  nothing  else  required  than  to  keep  the  canal 
well  cleansed,  so  as  to  obviate  any  irritation  that 
otherwise  might  be  induced  by  decomposition.  When 
the  pulp  has  been  destroyed  by  arsenious  acid,  more 
energetic  treatment  is  usually  demanded,  for  then 
there  is  always  a  greater  or  less  disposition  to  slough 
or  discharge  through  the  tooth,  which  must,  of  course, 
be  entirely  abated  before  the  operation  of  filling  is  at 
all  admissible.  In  the  treatment  of  this  condition 
the  canal  should  be  kept  perfectly  clean  by  frequent 
syringing;  floss  silk,  moistened  with  creosote  and 
tannin,  should  be  introduced  to  the  extreme  part  of 
the  cavity  or  canal,  and  should  be  changed  every 
twenty-four  hours,  the  cavity  being  thoroughly 
washed  each  time.  It  will  be  necessary,  in  many 
cases,  to  continue  this  treatment  for  several  days.  In 
order  to  determine  whether  the  condition  is  such  as 


TREATING    PULP-CAVITIES.  317 

to  admit  of  the  filling,  the  floss  silk  should  be  re- 
moved after  a  sufficient  time  is  supposed  to  have 
elapsed,  the  cavity  thoroughly  cleansed  and  dried, 
and  a  portion  of  dry  floss  silk  or  cotton  introduced 
loosely  into  the  canal.  Then  close  the  decayed  cavity 
with  adhesive  wax,  gutta-percha,  or  some  other  sub- 
stance that  will  effectually  exclude  the  moisture;  let 
it  remain  thus  from  twelve  to  twenty-four  hours; 
then  open  the  cavity  and  withdraw  the  silk  or  cot- 
ton, and  if  this  is  found  free  from  moisture  or  odor 
the  tooth  is  ready  to  be  filled. 

The  treatment  just  described  will  be  sufficient  for 
all  cases  in  which  the  pulp  has  been  destroyed  by  the 
operator.  But  teeth  whose  pulps  are  already  dead 
would  seem  to  be  less  difficult  of  treatment  and  fill- 
ing, yet  such  is  not  the  case;  indeed,  the  therapeutic 
treatment  of  these  is  usually  more  protracted,  and 
their  diseased  condition  less' easily  controlled;  and 
this  because  of  the  fact  that  the  decaying  pulp  re- 
maining in  the  canal  becomes  very  offensive  and 
irritating  to  the  living  parts  adjacent,  in  which  it 
induces  a  chronic  diseased  condition,  frequently 
involving  the  dentine  along  the  walls  of  the  canal  in 
decomposition. 

A  classification  of  these  teeth,  based  on  their  con- 
ditions, might  be  somewhat  auxiliary  to  a  further 
examination  of  this  subject,  and  the  following  will 
probably  embrace  them  all: 


318  PULP-CAVITIES. 

1st.  Those  whose  pulps  are  dead,  hut  their  attach- 
ments and  adjacenl  parts  alive  and  healthy. 

2d.  Those  predisposed  to  disease. 

3d.  Those  already  diseased,  either  discharging  ac- 
rid matter  through  the  root,  or  exhibiting  inflamma- 
tion of  the  periosteum. 

1th.  Those  having  alveolar  abscess. 

Sound  or  slightly  decayed  teeth  are  sometimes 
found  with  dead  pulps.  This  condition  may  be  pro- 
duced in  various  ways  :  by  blows,  or  by  any  force 
that  will  partially  loosen  the  tooth  ;  by  undue  pres- 
sure in  filling;  by  excessive  sensitiveness  of  the  den- 
tine, even  where  the  decay  is  not  extensive  ;  and, 
sometimes,  by  a  filling  of  the  tooth  when  it  is  in  an 
unfit  state  for  the  operation.  Ordinarily,  in  cases  in 
which  the  pulp  is  dead  before  its  exposure,  and  there 
is  no  abscess  from  the  root  or  periosteum,  the  pulp- 
chamber  maybe  opened  and  the  remains  of  the  pulp 
removed.  The  canal  should  then  be  cleansed  out, 
and  tloss  silk,  moistened  with  creosote,  introduced 
and  permitted  to  remain  from  one  to  six  hours,  when 
it  should  be  withdrawn,  the  pulp  cavity  and  the  canal 
again  thoroughly  cleansed,  when,  if  there  is  no  dis- 
charge of  pus  through  the  root,  it  may  be  filled.  The 
fact  that  the  dead  pulp  is  inclosed  in  its  chamber 
without  producing  irritation  is  evidence  that  there  is 
no  secretion  of  pus.  Occasionally,  where  the  pulp 
has  died  from  exposure,  the  living  part  immediately 


TREATING    PULP-CAVITIES.  319 

adjacent  will  present  a  healthy  condition,  and  there 
will  be  no  discharge  ;  such  cases  should  be  treated  in 
the  manner  just  described.  In  operating  on  teeth 
already  dead,  more  delicate  manipulation  is  requisite 
to  prevent  irritation  than  on  those  in  which  the  pulp 
is  destroyed  by  the  operator.  In  very  many  cases 
of  dead  teeth,  where  there  is  not  a  state  of  actual 
disease,  there  is  a  strong  predisposition  to  it ;  and  in 
these  cases  the  preparation  of  a  cavity,  or  the  intro- 
ducing and  condensing  of  a  filling,  may  produce  in- 
flammation of  the  periosteum.  When  such  a  condi- 
tion is  recognized,  several  sittings  may  be  required 
to  complete  the  operation.  It  is  not  always  easy  to 
recognize  such  a  predisposition  ;  yet  whenever  it  is 
suspected,  it  is  well  to  press  the  investigation,  which 
may  be  guided  by  the  following  rules.  Ascertain 
whether  the  tooth  experiences  a  different  sensation 
or  any  pain  under  percussion  in  any  direction ; 
whether  periostisis  has  ever  existed  in  that  or  in  a 
contiguous  tooth  ;  whether  the  parts  adjacent  to  the 
tooth  are  in  a  healthy  state;  whether  there  is  a  gen- 
eral inflammatory  diathesis  or  an  enfeebled  condition. 
These  are  the  principal  points  in  an  examination  of 
this  kind. 

Where  this  predisposition  exists,  it  may  be  coun- 
taracted  by  general  or  local  treatment,  according  as 
it  depends  on  general  or  local  causes  ;  but  in  every 
case,  this   treatment  should   be  very  carefully   con- 


320  PULPH  AVITIES. 

ducted,  and  it  will  in  some  instances  have  to  be  pro- 
tracted. In  those  cases  where  there  is  ;i  discharge 
through  the  root  of  the  tooth,  such  treatmenl  should 
be  adopted  as  will  most  speedily  and  effectually  sup- 
press it  :  and  it' it  proceeds  from  a  remaining  portion 
of  the  pulp-tissue  near  the  point  of  the  root,  this 
should  be  removed,  and  such  application  made  as 
will  prevent  a  recurrence  of  the  discharge,  and  assist 
the  part  to  recover  its  health.  The  discharging  sur- 
face may  be  broken  up  by  cutting  it  away  with  an 
instrument,  or  be  destroyed  with  an  escharotic — 
either  nitrate  of  silver,  creosote,  or  chloride  of  zinc, 
in  the  use  of  which,  several  applications  will  in  many 
cases  be  necessary.  From  their  action,  the  secreting 
surface  is  destroyed,  healthy  granulations  spring  up, 
and  a  healthy  condition  is  established. 

The  discharge  should  be  wholly  suppressed  before 
the  tooth  is  rilled,  otherwise  alveolar  abscess  would 
probably  occur.  In  cases  where  there  is  periostitis, 
it  must  be  subdued  before  the  tooth  will  tolerate  the 
operation  of  filling.  To  attain  this  end,  the  treat- 
ment required  will  be  indicated  by  the  nature  of  the 
causes  which  operate  to  induce  the  disease. 

The  periostitis  of  teeth  whose  pulps  are  dead  com- 
monly has  its  origin  at  the  point  of  the  root,  from 
irritation  induced  in  the  beginning  by  the  dead  and 
decomposing  pulp  and  other  matter  at  that  point.  In 
many  instances  the  inflammation   is  not  confined  to 


TEEATIXG    PULP-CAVITIES.  321 

the  root  of  the  tooth  on  which  it  began,  but  it  will 
extend  to  the  alveolus,  the  gums,  and  the  periosteum 
of  the  neighboring  teeth.  Whenever  the  existence 
of  this  disease  is  suspected,  and  yet  not  very  appar- 
ent, as  is  often  the  case,  the  examination  should  be 
very  thorough.  In  some  instances,  percussion  of 
the  tooth  at  one  particular  point,  and  at  a  certain 
angle,  will  produce  pain ;  whereas,  striking  on  any 
other  part  of  the  tooth,  or  at  any  other  angle,  will 
cause  none  at  all.  By  proper  care  and  discrimina- 
tion the  exact  point  of  disease,  even  if  confined  to  a 
small  space,  may  be  ascertained.  For  instance,  if 
striking  on  the  labial  surface  of  a  central  incisor,  near 
the  point,  produces  pain  in  the  socket,  while  on  any 
other  point  it  does  not,  the  place  of  the  inflammation 
is  the  anterior  portion  of  the  root,  at  or  near  its  point. 
By  such  means  the  skilful  and  discerning  will  be  en- 
abled to  form  a  tolerably  accurate  opinion  as  to  the 
extent  and  location  of  periostitis  in  all  cases  ;  and 
this  is  an  important  consideration,  for  if  inflamma- 
tion is  found  confined  to  a  small  portion  of  a  root, 
the  treatment,  if  local,  should  be  as  near  that  point 
as  possible. 

Inflammation  of  the  periosteum  may  sometimes  be 
induced  by  the  presence  of  foreign  substances  forced 
down  between  the  free  margin  of  the  gum  and  the 
neck  of  the  tooth,  which  have  remained  there  till  they 
have  become  vitiated,  so  as  injuriously  to  affect  the 

21 


322  PULP-CAVITIES. 

gums  and  periosteum.  A  deposit  of  salivary  calculus 
sometimes  produces  inflammation  of  the  gums  and 
periosteum.  Teeth  otherwise  healthy  are  in  some 
instances  thus  affected,  though  those  which  have  lost 
their  internal  vitality  are  much  more  liable  to  such 
disease. 

Preparing  the  Teeth  and  Roots  for  Filling. — After 
the  tooth  has  been  brought  to  a  healthy  condition, 
the  decayed  cavity  is  first  to  be  excavated  and  made  of 
proper  form,  the  pulp-chamber  to  be  shaped,  and  then 
the  canals  and  the  roots  to  be  prepared  for  filling. 
For  the  preparation  of  decayed  cavities  here,  the  di- 
rections hitherto  given  on  that  subject  will  be  quite 
sufficient.  In  the  formation  of  the  pulp-chamber  the 
abrupt  projecting  portions  of  dentine  should  be  cut 
down,  and  if  there  is  any  decomposition  of  this  it 
should  be  removed.  The  pulp-chamber  may  be,  when  it 
is  excavated,  of  a  general  retaining  form,  or  there  may 
be  retaining-points  made  within  it  at  proper  situations. 
In  the  preparation  of  the  canal  in  the  roots,  some  op- 
erators do  nothing  more  than  cleanse  them  thoroughly. 
Another  method  is  to  pass  fine  bur-drills  into  them  as 
far  as  practicable,  thus  making  the  opening  of  the 
same  size  all  the  way,  or  to  scrape  out  the  canal  with 
a  fine  No.  10  excavator.  Very  fine,  delicate  instru- 
ments are  required  for  cleansing  out  and  forming  the 
canals,  and  they  should  be  quite  elastic  and  of  low 
temper.     A  set  of  instruments  for  forming  the  canals 


FILLING    PULP-CANALS. 


323 


in  the  roots  of  the  teeth  have  been  devised  and  made 
by  Dr.  Cory  don  Palmer.  These  are  of  such  forms 
and  sizes  as  to  be  suitable  for  every  case.  They  are 
represented  in  Fig.  94.  Before  the  introduction  of 
these  instruments  the  method  of  forming  these  canals 
was  by  the  use  of  a  three  or  four  sided  broach,  taper- 
ing to  a  sharp  point,  and  in  inclination  corresponding 

Fig.  94. 


as  far  as  possible  to  that  of  the  canal.  This  instrument 
is  employed  to  enlarge  the  canal  and  give  it  a  regular 
shape;  a  variety  should  be  at  hand  so  that  one  of  the 
proper  size  and  taper  can  be  selected.  In  cleansing 
and  forming  the  canal,  care  is  necessary  to  prevent  the 
instrument  from  passing  entirely  through  the  point  of 
tin-  loot.  Such  an  accident  is  not  very  liable  to  occur 
with  the  tapered  broach,  but  with  the  miniature  ex- 
cavator, or  barbed  wire,  it  is,  especially  in  the  teeth  of 


324  PULP-CAVITIES. 

the  young,  where  the  foramina  through  the  roots  are 
large,  and  it  is  especially  liable  to  happen  to  the  in- 
cisors, the  cuspids,  and  the  palatine  roots  of  the  su- 
perior molars.  But  after  the  complete  development  of 
the  teeth  there  is  no  excuse  for  an  accident  of  this 
kind,  for  then  there  is  an  abrupt  contraction  of  the 
canal  near  the  point  of  the  root,  which  may  always 
be  detected  by  a  careful  introduction  of  the  instru- 
ment. 

The  decayed  and  pulp-cavities,  and  the  canal,  all 
being  thus  prepared,  are  now  ready  to  receive  the 
filling.  For  filling  the  root  there  are  several  methods, 
one  of  which  is  to  prepare  small  strips  of  gold,  of  two 
or  four  thicknesses  of  foil,  take  these  on  the  point  of 
an  instrument  and  pack  them  into  the  root,  in  suc- 
cessive folds,  till  the  canal  is  full.  Another  method 
is  to  take  small  portions  of  gold  and  pack  them  in, 
one  on  another,  till  the  canal  is  full.  Another  is  to 
take  strips  of  from  twTo  to  four  thicknesses,  and  from 
one  to  two  lines  wide,  and  roll  them  on  a  fine  broach 
in  such  a  manner  as  to  make  a  cone-shaped  block  a 
little  longer  than  the  depth  of  the  canal  to  be  filled, 
and  of  the  same  taper;  quite  a  number  of  these  blocks 
will  be  required  for  any  given  Gase,  of  various  sizes, 
lengths,  and  densities.  The  longest,  largest,  and  least 
dense  should  be  first  used,  the  last  requiring  to  be  of 
less  size  and  greater  density.  These  cones  may  be 
made  as  dense  as  desirable  by  rolling  them  firmly  be- 


FILLING   PULP-CANALS.  325 

tween  the  thumb  and  fingers  after  having  taken  them 
off  the  broach.  They  are  then  introduced  with  the 
plugging-pliers,  and  passed  up  as  near  to  the  point  of 
the  root  as  is  consistent  with  safety.  In  some  in- 
stances there  is  danger  of  thrusting  them  through  the 
point,  and,  in  order  to  prevent  this,  the  end  of  the  first 
block  introduced  may  be  made  so  large  that  it  will  not 
pass  through,  even  when  forced  up ;  or,  what  is  prob- 
ably better,  a  very  small  round  pellet  of  gold  may  be 
forced  into  the  canal,  as  near  to  the  point  of  the  root 
as  admissible,  and  this  serves  as  a  foundation  for  the 
subsequent  portions  of  gold,  and  prevents  them  from 
passing  too  far.  The  cone-shaped  blocks  may  be  intro- 
duced and  consolidated  with  an  instrument  of  the 
same  general  form  as  the  canal  but  much  smaller. 
This  kind  of  instrument  should  be  made  of  untem- 
pered  steel,  though  some  operators  make  them  of 
Avhalebone  to  prevent  breaking  in  the  canal, — an  un- 
necessary precaution,  since  no  skilful  operator  would 
ever  break  off  a  low-tempered,  well-polished,  prop- 
erly-formed steel  instrument  of  this  kind.  After  a 
Mock  is  placed  in  the  cavity  the  instrument  is  thrust 
in  by  its  side,  consolidating  the  gold  to  the  side  of  the 
cavity.  Thus  the  blocks  are  successively  introduced 
and  consolidated  till  the  canal  is  filled.  It  is  better 
so  to  arrange  as  to  introduce  the  last  portion  of  the 
gold  near  the  centre  of  the  canal,  rather  than  at  the 
side.     The  l;i.-t  blocks  introduced  should  be  stiff  and 


326 


PULP-CAVITIES. 


dense,  that  they  may  he  thrust  in  with  considerable 
force.  The  method  of  filling  canals  at  present  em- 
ployed by  many,  is  in  the  use  of  the  filling  instruments 
invented  by  Dr.  Corydon  Palmer,  represented  in  Fig. 
95.  There  is  a  variety  in  size,  and  somewhat  in  form, 
so  that  in  all  positions  they  will  readily  enter  the 
canals  and  effectually  consolidate  the  gold,  which  is 

Fig.  95. 


introduced  in  small  cone-shaped  pellets,  loosely  rolled 
so  that  they  may  be  thoroughly  condensed. 

Another  method  of  preparing  gold  for  filling  roots, 
is  to  take  the  pure  metal,  and  roll  it  down  on  a  good 
rolling-mill  as  thin  as  possible,  keeping  it  well  an- 
nealed ;  of  this  form  the  cones,  and  introduce  them 
as  already  directed.  Made  in  this  ,way,  they  are 
stiffer,  and  fill  up  much  more  rapidly  than  when 
made  of  foil.  They  are  to  be  condensed  in  the  same 
manner.  Where  the  canal  has  been  formed  with  a 
tapered  broach,,  it  may  be  filled  with  a  gold   wire, 


FILLING    PULP-CANALS.  327 

made  of  the  same  size  and  taper  of  the  broach  ;  this 
wire  may  be  cut  off  at  the  orifice  of  the  canal,  or  left 
protruding  more  or  less  into  the  decayed  cavity,  and 
be  covered  up  with  the  filling.  When  a  lost  portion 
of  the  form  of  a  tooth  is  to  be  restored,  such  pro- 
jecting wires  may  be  made  very  valuable  as  anchor- 
ages. 

Some  other  substances  have  been  thought  quite  as 
suitable  for  filling  the  roots  of  teeth  as  gold.  Lead 
has  been  employed  for  this  purpose  ;  but  the  principal 
difficulty  with  this  is,  to  get  it  into  such  a  condition 
as  to  be  used  with  facility ;  but,  if  as  completely  in- 
troduced, it  would  probably  answer  the  jimrpose  quite 
as  well  as  gold.  Dr.  F.  Peabody,  about  three  years 
ago,  described  a  method  of  filling  the  roots  of  teeth 
with  lead,  which  his  experience,  as  well  as  that  of  some 
others,  seems  to  indicate  in  many  cases  at  least  is  very 
good.  It  consists  simply  in  forming  the  canal  in  the 
root  slightly  tapering  from  the  pulp-chamber  to  its  ter- 
mination ;  then  form  from  a  lead  rod  a  cylinder  or  cone 
of  the  same  size  and  taper  as  the  canal  in  the  root; 
let  this  be  driven  firmly  to  its  place  in  the  root;  the 
rod  may  now  be  cut  off,  leaving  a  slight  projection 
from  the  entrance  to  the  canal ;  by  this  the  orifice  can 
be  viiv  perfectly  closed ;  then  the  pulp-chamber  and 
cavity  of  decay  may  be  filled  in  the  usual  manner. 
Tin  foil  ifi  also  used,  and  under  favorable  circumstances, 
with  success.     Gutta-percha,  dissolved  in  chloroform, 


32S  PULP-CAVITIEB. 

i-  used  to  some  extent,  and,  it  is  claimed]  with  deci- 
dedly good  results.  It  is  prepared  of  sucli  consistence 
as  to  be  readily  pumped  into  even  the  smallest  canals 
by  a  little  piston  made  by  wrapping  cotton  upon  a  fine 
broach  ;  and,  after  having  the  canal  prepared,  it  is 
filled  by  forcing  the  gutta-percha  solution  in  with  the 
appliance  referred  to.  It  is  claimed  that  this  method 
is  equal  to,  if  not  superior,  to  any  other,  since  by 
proper  manipulation,  every  canal,  however  crooked,  or 
small,  can  be  completely  filled ;  the  material  will  not 
be  dissolved  nor  deteriorated  ;  and  if  there  should  he  a 
slight  protrusion  through  the  end  of  the  root,  it  would 
not  irritate  the  tissue  with  which  it  would  come  in 
contact.  Some  experiments,  too,  have  been  made  with 
plaster  of  Paris  and  similar  substances,  for  filling 
roots  and  pulp-cavities,  but  with  rather  uncertain  suc- 
cess— some  claiming  instances  of  success,  and  others 
reporting,  in  every  instance,  failure;  so  that  there  are 
not  sufficient  data  to  warrant  the  adoption  of  plaster 
or  any  similar  substances  in  practice. 

In  cases  in  which  there  is  liability  to  irritation,  the 
operation  of  filling  a  root  is  quite  enough  for  one  sit- 
ting ;  and  in  any  case,  not  more  than  three  roots  should 
be  fdled  at  one  time.  The  filling  of  a  large  pulp-cav- 
ity will  occupy  one  sitting,  and  that  of  the  decayed 
cavity  another.  When  a  respite  is  thus  had  between 
the  filling  of  the  pulp-cavity  and  that  of  the  decayed 
cavity,  the  former  should  be  filled  with  Hill's  stop- 


FILLING    PULP-CANALS.  329 

ping  or  gutta-percha,  so  that  no  moisture  may  pene- 
trate it;  and  then  when  the  latter  part  of  the  filling 
is  to  be  introduced,  it  will  proceed  as  though  there 
had  been  no  interruption.  From  one  to  four  days 
should  intervene  between  the  different  divisions  of  the 
operation.  The  filling  of  the  decayed  cavity  is  to  be 
performed  according  to  the  directions  already  given. 
When  inflammation  ensues  after  an  operation  of  this 
kind,  recourse  is  had  to  the  treatment  already  de- 
scribed for  preventing,  counteracting,  or  reducing  in- 
flammation. 

Some  experiments  have  been  made  to  test  the  effect 
of  restoring  the  parts  to  health,  forming  a  cicatrice 
at  the  point  of  the  root,  cleansing  this  out,  filling 
the  pulp-cavity  and  the  cavity  of  decay,  and  leaving 
the  canal  unfilled ;  and  it  is  maintained  that  this 
method  will,  in  favorable  cases,  answer  the  purpose 
quite  as  well  as  that  of  filling  the  root,  and  incur  less 
risk.  The  treatment  will  be  such  as  already  described 
for  the  restoration  of  diseased  roots ;  all  discharge 
through  it  must  be  suppressed,  and  all  foreign  sub- 
stances liable  to  decomposition  removed  from  the  canal, 
so  that  there  may  be  a  complete  restoration  before  it 
is  closed. 

Oftentimes,  when  a  tooth  has  been  filled  without 
filling  the  roots  and  pulp-chamber,  if  the  pulp  be  dead, 
or  if  the  pulp  afterward  dies,  the  chamber  becomes  the 
receptacle  of  a  very  vitiated  and  acrid  material,  the 


330  PULP-CAVITIES. 

retention  of  which  will  almost  invariably  produce  irri- 
tation. In  all  such  cases,  an  opening  should  be  made 
for  the  escape  of  the  offensive  matter.  This  is  done. 
if  the  filling  is  not  to  be  removed,  by  passing  a  sum  11 
drill  into  the  pulp-chamber  or  canal,  just  above  the 
filling,  as  close  as  possible.  The  handle  of  the  drill 
should  be  depressed,  so  as  to  give  the  opening  a  down- 
ward inclination  from  within  outward,  and  thus  favor 
the  escape  of  any  secretion. 

In  the  superior  molarsr  this  opening  may  be  made 
through  the  masticatory  surface ;  it  may  sometimes  be 
in  the  depressions  on  the  crown  surface,  even  though 
there  be  no  filling.  In  incisors,  it  is  made  through  the 
j^alatine  portion  of  the  crown.  It  is  better,  however, 
in  all  cases,  to  make  an  opening  of  this  kind  through 
the  neck  of  the  tooth,  just  under  the  free  margin  of  the 
gum,  since  here  foreign  substances  are  not  so  liable  to 
be  crowded  into  it  as  where  it  is  through  the  mastica- 
tory surface.  In  cases  in  which  it  is  obvious  at  the  time 
of  filling  the  tooth  that  such  an  opening  will  be  re- 
quired, it  is  better  to  make  it  before  the  filling  is 
introduced,  as  follows  :  first,  prepare  the  decayed  and 
pulp-cavities  for  filling ;  then  drill  through  the  neck 
of  the  tooth  into  the  canal,  to  the  extreme  part  of  the 
pulp-chamber  ;  and  finally  introduce  into  this  hole, 
its  entire  depth,  a  piece  of  smooth  steel  wire,  such  as 
will  closely  fit,  leaving  it  exposed  through  the  decayed 
cavity — and  if  it  is  not  enough  exposed  when  intro- 


DENTAL    PERIOSTITIS.  331 

duced,  the  tooth-bone  may  be  cut  away  about  it,  till  it 
is  fully  exposed,  when  the  decayed  and  pulp-cavities 
are  filled  in  the  usual  manner,  and  condensed  solidly 
against  the  wire.  After  the  filling  is  finished,  the  wire 
is  withdrawn,  leaving  a  smooth,  continuous  opening 
for  the  escape  of  any  secretion  that  may  collect  within. 
When  the  opening  into  the  canal  is  not  made  till  after 
the  tooth  is  filled,  there  is  liable  to  be  a  space  between 
it  and  the  filling  that  will  receive  and  retain  fetid  mat- 
ter, which  may  become  very  offensive.  This  method 
of  treatment  is,  however,  always  to  be  deprecated,  and 
should  never  be  employed  except  as  a  last  resort,  or 
in  cases  where  it  is  impossible  to  command  the  time 
and  opportunity  for  the  proper  treatment ;  and  even 
then  it  is  better  to  make  the  opening  and  entrance  into 
the  chamber  and  canal  just  as  though  it  were  to 
receive  immediate  treatment;  for  in  a  great  many 
instances  the  opportunity  for  that  may  soon  occur. 

Dental  Periostitis. 

This  affection  of  the  investing  membrane  of  the 
roots  of  the  teeth  is  of  frequent  occurrence  after  the 
death  of  the  pulp,  but  rarely  if  ever  before.  Inflam- 
mation of  this  tissue,  in  its  manifestation,  is  modified 
by  the  anatomical  structure  of  the  parts. 

Whether  there  be  two  membranes  in  the  alveolar 
sockets,  the  one  lining  the  walls  of  these,  and  the  other 


332  DENTAL    PERIOSTITIS. 

investing  the  roots  of  the  teeth,  is  not  a  matter  of  im- 
portance so  far  as  the  nature  and  treatment  of  this 
affection  is  concerned.  This  condition  of  the  dental 
periosteum  is  induced  by  such  irritating  causes  as  would 
produce  inflammation  in  other  tissues. 

The  first  indication  of  approaching  difficulty  in  this 
tissue  is  a  sense  of  slight  fulness,  which  invites  con- 
tact, and  even  pressure  from  the  opposing  teeth — such 
pressure  affording  a  rather  pleasurable  sensation  and 
seeming  relief. 

This  condition  is  brought  about  by  determination  of 
blood  to  the  part,  and  the  surroundings  being  such  as 
to  prevent  free  expansion  to  the  capillaries,  and  other 
small  vessels  ramifying  this  membrane,  these  walls 
are  pressed  upon  in  proportion  to  the  force  of  this  de- 
termination. 

This  effort  at  exj:>ansion  will  occasion,  especially  in 
those  teeth  having  very  conical  roots,  quite  a  percep- 
tible elongation,  and  this  more  particularly  occurs  when 
active  inflammation  supervenes,  which  is  the  sequence 
of  the  state  of  irritation  to  which  reference  has  just 
been  made. 

After  active  inflammation  has  occurred,  pressure  or 
percussion  upon  the  affected  tooth  usually  causes  great 
pain, — to  such  an  extent  that  sometimes  the  slightest 
contact  even  by  the  tongue  is  intolerable. 

This  condition  varies  much  in  degree  in  different 
cases,  dependent  largely  upon  the  predisposition  and 


DENTAL    PERIOSTITIS.  333 

susceptibility  to  exciting  causes  of  irritation  and  in- 
flammation, together  with  the  character  of  these  ex- 
citing causes,  whether  concentrated  in  action  to  a 
mere  point,  or  more  extensive  in  their  sphere  of  op- 
eration. 

Oftentimes  only  a  very  small  portion  of  the  perios- 
teum of  a  tooth  will  be  affected  ;  it  may  be  confined  to 
the  immediate  vicinity  of  the  point  of  the  root,  or  to 
one  side,  or  to  the  periosteum  near  the  margin  of  the 
alveolus  and  the  border  of  the  gum. 

Indeed,  so  circumscribed  is  this  affection  often  found, 
that  the  periosteum  on  one  side  of  a  root  will  pass 
through  all  the  successive  stages  of  inflammation  to 
suppuration  and  destruction,  without  that  upon  the 
opposite  side  having  undergone  anything  more  than  a 
slight  irritation,  if  even  that.  In  such  cases  the  vital- 
ity  has  sufficient  power  to  hold  the  disease  at  bay,  and 
confine  it  to  the  immediate  point  of  attack. 

AVhen  there  is  a  systemic  predisposition,  the  local 
exciting  causes  will  sooner  and  more  vigorously  at- 
tack. Always  when  the  pulp  of  a  tooth  is  devital- 
ized, the  periosteum  is  more  liable  to  disease,  and  per- 
haps lor  several  reasons.  In  almost  all  cases  there 
are  irritants  at  hand  that  did  not  exist  before;  and 
the  periosteum  is  either  enfeebled,  and  consequently 
Less  resistant,  or  the  demand  upon  its  function  greater 
than  before,  in  view  of  its  being  the  medium  of  con- 
nection  between   the  normally   vital  tissue  and  that 


334  DENTAL   PERIOSTITIS. 

which  is  devitalized,  or,  at  best,  its  life  very  much  im- 
paired ;  and  when  the  latter  condition  exists,  the  nour- 
ishment received  by  the  cementum  and  dentine  is 
wholly  through  the  periosteum.  In  these  facts  doubt- 
less are  to  be  found  the  cause  of  the  greater  suscepti- 
bility of  the  dental  periosteum  to  disease  after  than 
before  the  death  of  the  pulp. 

The  exciting  causes  of  this  affection  are  to  be  found 
in  the  acrid  debris  of  the  dead  and  decaying  pulps  of 
the  teeth,  passing  either  in  a  fluid  or  gaseous  state 
through  the  foramen  at  the  point  of  the  root,  and  there 
coming  in  contact  with  the  periosteum,  and  in  various 
deposits,  calcareous  and  others,  insinuated  beneath  the 
margin  of  the  gum,  encroaching  upon  and  irritating 
the  periosteum. 

It  is  also  sometimes  occasioned  by  an  extension  of 
disease  from  some  other  point.  As  an  illustration  of 
this,  in  susceptible  cases,  the  periosteum  of  one  tooth 
may  become  affected  by  the  action  of  some  local  irri- 
tant, and  two  or  more  of  its  neighbors  become  affected 
by  extension  of  the  inflammation. 

Some  medicinal  agents  act  specifically  upon  the 
dental  periosteum,  inducing  a  very  painful  condition, 
thickening  of  the  tissue,  and  elongation  of  the  teeth. 

Mercurials  present  an  illustration  of  this  class  of 
agents.  The  precise  condition  produced  in  the  den- 
tal periosteum  in  mercurial  ptyalism  is  perhaps  not 
clearly  comprehended.    It  is  more  than  simple  inflam- 


DENTAL    PERIOSTITIS.  335 

mation.  It  is  not  modified  or  controlled  by  the  same 
remedial  treatment.  It  attacks  the  periosteum  of  liv- 
ing- teeth  as  readily,  and  with  quite  as  much  violence, 
as  of  those  which  are  devitalized.  Alveolar  abscess 
is  not  a  common  result  of  this  affection  of  the  perios- 
teum. 

Treatment. — The  treatment  of  dental  periostitis,  in 
its  details,  will  be  governed  by  the  attendant  condi- 
tions, such  as  systemic  predispositions,  the  vital  force, 
and  the  local  causes,  and  their  peculiarities. 

Systemic  treatment  should  have  for  its  object  the 
removal  or  counteracting  of  predispositions,  and  the 
abatement  of  the  determination  of  blood  to  the  part 
in  question,  by  inviting  it  to  other  parts,  by  their 
stimulation,  and  by  introducing  into  the  system  such 
agents  as  will  tend  to  allay  excitement  in  the  affected 
part,  and  induce,  so  far  as  possible,  an  equilibrium 
of  circulation  throughout  the  system. 

The  local  treatment  must  also  be  wisely  and  faith- 
fully attended  to.  The  principle  applicable  to  the 
treatment  of  inflammation  in  any  tissue  is  that  to  be 
employed  here.  It  will  be  remembered,  however, 
that  there  are  many  medicinal  agents  which  possess 
v<  i  v  desirable  properties  that  are  still  totally  ineffi- 
cient, because  of  a  want  of  adaptation.  We  have, 
however,  at  our  command  some  very  efficient  reme- 
dial agents  for  the  treatmenl  of  this  affection,  and  the 
li-t  i-  being  constantly  enlarged. 


336  DENTAL   PERIOSTITIS. 

We  propose  here  to  consider  rather  the  principles 

involved  in  the  treatment  than  the  details  for  special 
cases. 

The  causes  producing  and  influencing  the  disease 
should  always  be  fully  apprehended,  immediately  after 
which  the  following  points  should  receive  attention  : 
First  remove  all  irritants  ;  this  will  embrace  the  re- 
moval of  the  dead  pulp,  and  all  the  debris  from  its 
chamber,  and  from  the  canal  in  the  root  or  roots,  and 
rendering  them  perfectly  free  from  all  offensive  ma- 
terial, and  keeping  them  so  ;  and  the  removal  of  all 
deposits  that  may  be  upon  the  teeth,  especially  those 
that  may  encroach  upon  the  gum,  or  the  alveolus  and 
periosteum  at  or  beyond  the  neck  of  the  tooth  ;  also 
the  removal  of  all  injurious  and  useless  teeth  and  roots 
in  the  vicinity. 

Secondly,  relieve  the  congestion  of  the  affected  part, 
in  some  or  all  of  the  following  ways  :  either  by  sys- 
temic influence,  as  already  suggested,  or  by  counter- 
irritation,  producing  determination  to  a  neighboring 
part,  and  thus  relieving  the  affected  part,  or  by  de- 
pletion from  the  gum  immediately  opposite  the  seat  of 
the  affection. 

Counter-irritation  may  be  effected  by  scarifying  the 
gum,  or  by  the  application  of  some  irritating  agent, 
such  as  tincture  of  capsicum,  tincture  of  iodine  and 
cantharides.  An  excellent  preparation  of  the  latter, 
denominated  cantharidal   collodion,  is  very  effective. 


DENTAL   PERIOSTITIS.  337 

This  preparation  when  applied  to  the  gum  acts 
promptly  and  efficiently  in  almost  every  case  of  acute 
dental  periostitis ;  it  produces  desquamation  upon 
the  surface  of  the  mucous  membrane  where  it  is  ap- 
plied. 

Counter-irritation  may  be  produced,  also,  by  mak- 
ing a  deep  incision  in  the  gum  opposite  the* 'tooth 
affected,  and  introducing  a  little  flock  of  floss  or  cotton, 
saturated  with  creosote,  which  is  to  be  kept  in  place 
till  the  inflammation  of  the  periosteum  is  allayed, 
which  will  be  effected  in  from  one  to  five  days.  The 
silk  or  cotton  should  be  changed  every  day  till  the 
restoration  of  the  tooth  to  health  is  effected,  when  it 
is  to  be  removed,  and  the  wound  permitted  to  heal. 
Mild  stimulating  applications  to  the  gums  in  the  im- 
mediate vicinity,  to  increase  the  circulation,  will  in 
some  cases  be  quite  sufficient.  A  vapor  bath,  or  warm 
water  applied  to  the  part,  is  often  beneficial ;  and  in 
some  cases  a  continued  application  of  cold  by  means 
of  ice-water,  will  arrest  inflammation  of  the  perios- 
teum. 

The  tincture  of  aconite-root  is  a  valuable  local  ap- 
plication. It  is  a  powerful  sedative  and  antiphlogistic 
remedy.  This,  with  equal  parts  of  tincture  of  opium 
and  chloroform,  constitutes  a  very  valuable  local  rem- 
edy for  periostitis.  It  may  be  applied  by  occasionally 
moistening  the   gum  with   it,  or   by  placing  on  the 

gum,  opposite  the  seat  of  the  affection,  a  small  pad 

22 


338  DENTAL    PERIOSTITIS. 

of  bibulous  paper  or  lint  moistened  with  t lie  prepa- 
ration, which  may  remain  from  three  to  five  minutes. 
This  may  be  repeated  as  occasion  may  require;  usu- 
ally, however,  from  one  to  three  applications  will  be 
sufficient. 

Depletion  with  many  is  a  favorite  method  of  treat- 
ment, and  is  often  productive  of  very  good  results. 
Two  or  three  methods  of  accomplishing  this  are  em- 
ployed. Simple  scarification  of  the  gum,  cutting  it 
more  or  less  deeply,  will  secure  sufficient  haemor- 
rhage, especially  if  the  gums  are  quite  vascular ;  when 
this  fails,  cupping,  or  the  artificial  leech,  may  be  em- 
ployed; but  the  natural  leech  is  the  most  efficient 
means  of  local  depletion  in  this  treatment;  and  every 
dentist  should  always  have  these  at  command,  and  be 
familiar  with  their  use.  The  ajiplication  of  a  leech, 
in  very  many  cases,  will  in  a  short  time  subdue  the 
most  violent  attack  of  acute  periostitis. 

In  the  treatment  of  this  affection,  hypodermic  in- 
jections give  promise  of  most  desirable  results;  for 
this  purpose  the  solution  of  morphine  or  tincture  of 
opium,  from  ten  to  twenty  drops,  may  be  injected, 
with  a  proper  syringe,  beneath  the  mucous  mem- 
brane, when  the  pain  will  be  found  to  subside  in  a 
few  moments,  and  the  severest  symptoms  be  abated  in 
a  few  hours. 

In  all  cases  of  periostitis,  the  sooner  it  can  be 
brought  under  proper  treatment  after  the  attack  the 


ALVEOLAR    ABSCESS.  339 

more  easily  will  it  be  subdued.  In  cases  of  longer 
standing,  where  the  affection  has  assumed  a  chronic 
form,  the  membrane  more  or  less  thickened  and  in- 
durated, and  a  persistent  soreness  of  the  tooth  affected, 
heroic  and  persevering  treatment  will  be  required  to 
overcome  the  difficulty  ;  in  the  great  majority  of  cases, 
however,  the  result  is  the  formation  of  alveolar  ab- 
scess, rather  than  the  condition  just  referred  to,  a 
description  and  treatment  of  which  will  next  receive 
consideration. 

Alveolae  Abscess. 

"When  inflammation  occurs  in  the  periosteum  to  the 
extent  that  the  structural  character  of  the  tissue  can 
no  longer  be  maintained,  then  disintegration  begins  in 
it,  and  the  surrounding  tissue  also,  so  far  as  it  may 
be  involved.  "When  the  condition  arrives  in  which 
the  life  action  ceases,  the  tissue  at  once  begins  to  un- 
dergo solution,  and,  in  addition  to  this,  the  pabulum 
or  nutrient  material,  brought  into  the  diseased  terri- 
tory, is  for  the  most  part  vitiated,  its  nutrient  quality 
destroyed,  and  it  is  converted  into  debris,  except  that 
from  it,  under  favorable  circumstances,  coagulated 
lymph  is  formed,  which  constitutes  what  has  been  bo 
generally  denominated  the  sac,  and  by  some  the  pus- 
secreting  sac,  and  by  others  the  pyogenic  membrane. 

N<»w,  strictly,  it  is  not  any  of  these,  but  is  simply 
a    mass  ©f  coagulated    lymph,    varying    in   quantity, 


340 


ALVEOLAE    AB 


when  it  exists at  all,  from  a  little  shred  or  bleb,  thai  is 
lint  little  more  than  visible,  to  a  mass  as  Large  as  the 
tooth  to  which  it  is  attached.  As  to  its  location,  it 
varies;  sometimes  it  is  embraced   by  and  fills  up  the 

space  between  the  roots  of  the  molars,  either  superior 
or  inferior.  In  some  cases  it  is  merely  an  irregular 
mass  attached  to  the  end  of  the  root  about  which  the 
disease  is;  in  other  cases  it  will  cover  a  large  part  of 
the  surface  of  the  root  or  roots  involved.  The  accom- 
panying illustration  (Fig.  96)  represents  the  position 

Fig.  90. 


of  the  lymph  mass  on  the  roots  of  different  teeth.  It 
will  be  more  or  less  firmly  attached,  according  to  the 
extent  of  the  disintegration  of  the  periosteum,  being 
less  adherent  when  there  is  the  greater  destruction  of 
the  tissue.  A  portion  will  sometimes,  upon  the  re- 
moval of  the  tooth,  remain  in  the  socket,  with  some 
attachment,  though  usually  but  slight,  to  the  walls; 
this,  however  is  not  its  usual  place  of  lodgment  and 
attachment.  The  density  of  this  lymph  mass  varies 
in  different  cases.  Sometimes  it  is  quite  dense,  firm, 
and  resistant;  at  other  times  so  soft  and  flabby  as 


ALVEOLAR    ABSCESS.  34l 

hardly  to  support  its  own  weight.  Now,  that  this 
substance  is  instrumental  in,  or  has  anything  to  do 
with  secreting  or  forming  pus,  or  the  material  dis- 
charged from  an  alveolar  abscess,  is  not  established  nor 
warranted  by  deduction  nor  by  fact. 

Now,  the  question  occurs,  what  is  the  object  of 
this  product?  It  may,  in  the  first  place,  be  regarded 
as  an  abortive  effort  for  the  repair  of  lost  tissue,  and, 
in  the  second  place,  the  encystment  of  the  disease- 
producing  agent.  Neither  of  these,  however,  can  be 
accomplished.  Repair  cannot  take  place  so  long  as 
the  disease-producing  agent  is  present;  and  the  char- 
acter of  the  agent  or  agents,  and  the  anatomical  struc- 
ture of  the  parts,  preclude  encystment.  The  local 
agents  that  occasion  alveolar  abscess  may  be  in  form 
either  solid,  soft-solid,  fluid  vapor  or  gas.  Some  of 
these  could  not  be  encysted  in  any  anatomical  struc- 
ture, and  none  of  them  can  be  in  the  tooth  socket. 
This  lymph  mass  is  not  only  of  no  service  in  respect 
to  repaint  ion,  but  is  a  real  obstacle  to  the  proper  ac- 
complishment of  thai  process.  This  is  fully  recog- 
nized in  all  the  proposed  plans  of  remedy;  its  remo- 
val is  always  regarded  as  an  important  factor  in  the 
treatment. 

The  character  of  the  discharge  from  alveolar  ab- 
scess differs  greatly  in  different  cases,  and  somewhat 
;il    different  periods    of  the   same   case.      It  sometimes 

consists  of  pure   or  laudable  pus;  this   is  of  a,  yel- 


342  ALVEOLAE   ABSCESS. 

lowish-white  color,  opaque,  inodorous,  sweetish  taste, 
and  of  a  creamy  consistence.  In  the  majority  of 
cases  it  varies  from  this,  however,  exhibiting  less  the 
character  of  pus,  with  diminution  of  pus  corpuscles, 
and  an  increase  of  vitiated  ichorous  fluid,  in  which 
sometimes  pus-corpuscles  are  not  found  at  all,  with  an 
acridity  so  great  as  to  excoriate  living  tissue  whenever 
it  comes  in  contact  with  it. 

Usually  when  pure  pus  is  secreted,  coagulated 
lymph  will  be  found  most  abundant;  and,  on  the 
other  hand,  when  a  highly  vitiated,  acrid  discharge  is 
found,  there  will  be  almost,  if  not  an  entire  absence 
of  the  lymph  mass. 

The  character  of  the  discharge  is  modified  by  the 
systemic  condition,  by  the  tissue  disintegrated,  and 
by  the  character  of  the  local  irritants ;  and  it  can  only 
be  changed  by  a  modification  of  the  first  of  these,  and 
the  removal  of  the  latter. 

The  size  of  the  abscess  cavity  varies  in  different 
cases;  in  some  it  is  quite  small,  involving  a  very 
little  territory,  in  the  immediate  vicinity  of  the  point 
of  irritation ;  in  others  it  becomes  enlarged,  some- 
times to  twice  the  size  of  the  tooth  about  which  it  is. 
This  difference  arises  from  the  varying  severity  of 
the  disease,  and  the  peculiar  susceptibility  of  the 
parts. 

Usually  the  cavity  has  attained  its  full  size  before 
the  evacuation  of  the  pus;    and  if  this  is  benign, 


ALVEOLAR   ABSCESS.  343 

little  or  no  disintegration  takes  place  afterward ;  but 
it  may  be  otherwise  if  the  secretion  is  acrid. 

In  an  abscess  rapidly  formed,  there  is  very  con- 
siderable pressure  by  the  contents  upon  the  walls  of 
the  cavity  while  it  is  closed,  and  this  is  always  the 
cause  of  pain,  which  in  many  instances  is  very  severe. 
So  soon  as  an  opening  is  effected,  and  the  tension  re- 
lieved, the  pain  in  a  great  measure  ceases. 

There  are  various  directions  through  which  open- 
ings are  made  for  the  escape  of  the  pus.  Sometimes 
the  discharge  is  through  the  root^  sometimes  from  be- 
tween the  tooth  and  alveolus,  and  at  other  times  di- 
rectly through  the  alveolus  and  gum.  There  are 
occasional  cases  in  which  the  discharge  will  be  at  a 
very  considerable  distance  from  the  point  of  secretion ; 
but,  in  such  cases,  it  always  follows  some  natural  ave- 
nue that  affords  a  facility  for  its  passage,  as,  for  in- 
stance, along  a  suture.  There  are  cases  recorded  where 
the  issue  from  an  abscess  of  the  central  incisor  was 
near  the  posterior  portion  of  the  hard  palate,  and  in 
these  the  channel  of  the  pus  lay  along  the  suture  of 
the  palate  bones.  Sometimes  the  opening  from  an 
access  of  the  first  or  second  molar  will  be  opposite 
the  bicuspids  on  the  buccal  jX)rtion  of  the  gum.  Al- 
veolar abscess  is  exceedingly  variable  in  character, 
according  to  the  constitutional  peculiarities  and  sus- 
ceptibilities  of  the  patient,  the  condition  of  the  parts 
immediately  adjacent,  and,  to  some  extent,  the  caiuse 


344  AXVEOLAB    A.BSCE88. 

which  has  produced  it.  In  a  good  constitution,  after 
;in  abscess  is  formed,  it  will  discharge  healthy  pus. 
Occasionally,  yet  very  seldom,  does  nature  alone  effect 
a  permanent  cure.  In  constitutions  of  a  cachectic 
diathesis  alveolar  abscess  is  liable  to  constant  discharge 
of  an  unhealthy  pus,  or  purulent  acrid  matter,  and 
the  parts  about  it  are  usually  in  a  diseased  condi- 
tion. 

The  cases  in  which  alveolar  abscess  is  most  likely 
to  occur  are  those  of  a  manifest  inflammatory  dia- 
thesis, or  those  in  which  there  is  considerable  local 
inflammation  from  some  local  exciting  cause.  In  the 
cases  of.  constitutional  predisposition,  the  abscess  after 
a  time  assumes  a  chronic  character,  constantlv  secretins; 
and  discharging  pus,  but  does  not  usually  cause  much 
pain,  though  the  tooth  from  which  it  ]~)roceeds  will 
.experience  some  soreness  and  an  uneasy  sensation. 
In  the  acute  forms  of  it,  however,  there  will  be  intense 
pain.  In  some  cases  an  abscess  will  be  formed  with- 
out much  irritation  of  the  surrounding  parts,  while 
in  others,  irritation  and  inflammation  will  extend  to 
parts  more  remote,  especially  if  there  are  active  irri- 
tating agents  at  work. 

Treatment. — The  treatment  of  alveolar  abscess  will 
be  governed  by  the  constitution  of  the  patient  and 
the  condition  of  the  part  affected ;  a  case  of  recent 
origin  will  yield  much  more  readily  than  one  of  long 
standing.     When   a   case   has   assumed   the   chronic 


TREATMENT   OF    ALVEOLAR    ABSCESS.  345 

form,  and  the  surrounding  parts  have  become  impli- 
cated in  the  diseased  condition,  a  restoration  to  health 
is  often  very  difficult.  In  the  earlier  periods  of  the 
profession,  the  removal  of  alveolar  abscess  was  thought 
to  be,  as  a  general  thing,  wholly  impracticable.  But 
by  the  treatment  now  employed  this  affection  is 
readily  eradicated,  unless  the  parts  in  the  immediate 
vicinity  are  very  much  involved.  In  some  cases  the 
accumulation  of  coagulated  lymph  and  debris  on  the 
point  of  the  root  is  very  large,  and  absorption  has 
taken  place  to  accommodate  it;  in  such  instances,  this 
being  destroyed,  the  space  occupied  by  it  will  be  filled 
up  with  a  healthy  tissue.  In  young  persons,  when 
an  abscess  is  formed  on  the  point  of  a  root,  especially 
in  the  single-root  teeth  of  the  superior  maxilla,  the 
discharge  is  frequently  through  the  tooth  in  conse- 
quence of  the  large  size  of  the  foramen  at  the  point 
of  the  root,  and  generally,  in  such  cases,  the  local 
treatment  may  be  made  through  the  canal.  Sometimes 
the  discharge  is  between  the  root  and  the  wall  of  the 
alveolus.  More  often,  however,  especially  in  persons 
after  complete  development,  the  discharge  is  through 
the  alveolus  and  the  soft  parts  to  the  surface,  by  the 
shortest  course. 

When  an  alveolar  abscess  is  influenced  by  any  con- 
stitutional derangement,  general  treatment  must  be 
resorted  to,  such  as  the  condition  indicates.  The  local 
treatmenl  always  demanded  is  such  as  will  break  up 


346  ALVEOLAR   ABSCESS. 

and  destroy  the  accumulated  lymph  mass.  This  is 
effected  either  by  surgical  or  therapeutic  treatment, 
and  frequently,  in  chronic  cases,  by  both  together,  but 
in  the  great  majority  of  acute  cases  therapeutic  treat- 
ment alone  will  be  sufficient.  In  order  to  break  up 
an  abscess  by  an  operation  it  must  be  easy  of  access; 
and  it  is  very  seldom  that  an  operation  of  this  kind 
can  be  performed  through  the  root  of  a  tooth ;  but, 
fortunately,  in  almost  all  those  cases  where  the  dis- 
charge is  through  the  root,  therapeutic  treatment  alone 
will  answer  the  purpose.  When  the  point  of  discharge 
is  on  the  gum  opposite  the  accumulation  on  the  root,  a 
sharp-pointed  bistoury  may  be  used,  and  the  canal  of 
discharge  sufficiently  opened  to  admit  the  free  use  of 
the  instrument  at  the  seat  of  the  disease.  Then  the 
lymph  mass  should  be  dissected  from  the  point  of  the 
root  and  removed  as  completely  as  possible.  After 
this,  if  the  case  is  a  favorable  one,  nature  may  be  left 
to  accomplish  the  work,  in  which  case  the  detached 
material  will  be  thrown  off,  healthy  granulations  de- 
veloped, and  the  parts  restored  to  complete  health.  In 
other  cases,  however,  after  an  operation,  nature  unaided 
will  not  complete  the  cure,  but  such  therapeutic  treat- 
ment must  be  resorted  to  as  the  circumstances  seem  to 
require.  In  some  cases  the  opening  through  the  al- 
veolus will  require  to  be  enlarged,  and  this  part  of  the 
operation  requires  great  care.  All  loose  particles  of 
bone  should  be  removed  from  the  opening,  since,  if 


TREATMENT   OF    ALVEOLAR    ABSCESS.  347 

permitted  to  remain,  they  would  produce  irritation 
and  tend  to  increase  the  difficulty. 

When  the  therapeutic  treatment  is  applied  through 
the  root,  the  canal  is  to  be  cleansed  of  all  foreign  and 
detached  matter,  and  opened  freely  through  to  the 
point ;  and  if  the  discharge  is  fetid,  some  disinfectant 
and  antiseptic  should  be  used.  The  cleansing  of  the 
root  may  be  accomplished  by  injection  of  chloride  of 
sodium ;  after  which  the  agent  to  act  on  the  disease  at 
its  seat  is  to  be  introduced.  There  are  a  number  of 
agents  used  for  this  purpose,  the  chief  of  which  are 
salicylic  acid,  chloride  of  zinc,  nitrate  of  silver,  and 
creosote,  the  first  being  applied  in  the  solid  and  the 
others  in  the  liquid  state — though  the  nitrate  may  be 
employed  in  the  solid  form.  After  this,  during  two  or 
three  days,  floss  silk,  moistened  with  a  mild  solution 
of  creosote  and  tannin,  in  alcohol,  should  be  applied 
daily ;  and  then  clean  silk  or  cotton  may  be  worn  in 
the  canal,  changed  every  day,  for  three  or  four  days, 
or  till  it  is  manifest  that  there  is  no  longer  any  dis- 
charge, and  that  the  parts  are  in  a  healthy  condition. 
If  nitrate  of  silver,  in  solution,  or  creosote,  is  used,  a 
piece  of  floss  silk  should  be  moistened  with  it,  and 
passed  through  the  root  in  the  manner  already  de- 
scribed. The  nitrate  is  more  prompt  in  action  than 
creosote,  and  will  accomplish  a  specific  object  in  a 
shorter  time.  Either  of  these  solutions  may,  by  the 
use  of  the  syringe,  be  very  effectively  thrown  through 


348  ALVEOLAE    ABSCESS. 

a  root  in  the  following  manner  :  Fill  the  orifice  of  the 
canal  with  gutta-percha  ;  drill  through  it  a  hole  large 
enough  to  receive  tightly  the  point  of  the  syringe  ;  and 
then,  charging  with  the  solution,  inject  it  through  the 
root;  in  cases  where  there  is  an  opening  through  the 
gum,  the  injection  may  be  forced  round  through  this. 
The  condition  of  the  parts  will  indicate  how  long  this 
kind  of  treatment  should  continue.  Ordinarily,  when 
the  discharge  is  entirely  through  the  gum,  the  bistoury 
should  be  used  to  enlarge  the  opening;  or  in  some 
cases  it  is  preferable  to  use  the  "  sea-tangle  "  tent ;  for 
this  purpose  form  a  plug  of  this  material,  in  size  to  fit 
closely  into  the  fistulous  opening,  where  it  should  be 
placed  and  remain  for  twenty-four  to  forty-eight  hours. 
When  saturated  with  moisture,  the  tent  expands  to 
more  than  double  its  size  when  in  the  dry  state.  Care 
should  be  exercised  lest  too  much  irritation  is  produced 
by  the  pressure ;  this,  however,  can  be  easily  regulated. 
In  many  cases  therapeutic  treatment  alone  will  accom- 
plish the  object;  and  when  the  opening  is  large  and 
direct,  the  therapeutic  agents  may  be  introduced 
through  it  directly  to  the  seat  of  disease.  If  nitrate  of 
silver,  in  solution,  or  creosote,  is  used,  it  should  be  in- 
troduced to  the  point  of  affection  on  a  pledget  of  cotton 
or  floss  silk,  as  heretofore  directed  ;  or  if,  as  is  prefer- 
able, chloride  of  zinc  or  nitrate  of  silver  in  solid,  it 
should   be  passed  through  the  opening  into  the  main 


TREATMENT   OF   ALVEOLAR    ABSCESS.  349 

cavity.  This  treatment  should  be  kept  up  till  the  in- 
dications are  fulfilled. 

In  the  treatment  of  abscess  of  the  inferior  maxilla, 
much  difficulty  is  often  experienced  from  a  want  of 
free  egress  for  the  pus  and  debris.  While,  in  the  supe- 
rior teeth,  the  pus  may  frequently  escape  through  the 
tooth  by  gravitation,  this  force  in  the  inferior  jaw  in- 
creases the  difficulty.  The  secretion  being  made  at 
the  bottom  of  the  socket,  it  remains  there,  and  is  fre- 
quently pent  up  till  it  finds  an  outlet  through  the  gum, 
somewhere  between  the  point  of  the  root  and  the  neck 
of  the  tooth.  It  is  in  many  instances  very  difficult  to 
get  an  opening  as  low  down  as  the  point  of  the  root, 
since  the  buccal  attachment  to  the  gum  is  usually  quite 
above  that  point,  particularly  in  the  case  of  the  molars 
and  bicuspids.  Very  seldom,  if  ever,  can  the  coagu- 
lated lymph  on  the  root  of  an  inferior  tooth  be  de- 
stroyed by  treatment  applied  through  the  canal  of  the 
root.  Some  are  accustomed  to  make  a  vertical  incision 
of  the  gum,  as  low  as  the  point  of  the  root,  and  perfo- 
rate the  alveolus,  and  treat  through  this  channel, 
as  already  described.  Owing  to  the  disadvantage 
above  mentioned,  much  more  energetic  treatment  is 
necessary  to  attain  success  with  an  abscess  of  the  infe- 
rior than  with  that  of  the  superior  teeth. 

In  the  majority  of  cases,  where  one-half  or  more  of 
the  periosteum  of  a  root  is  involved  in  abscess,  the  in- 
dications are  generally  supposed  to  point  to  the  re- 


350  ALVEOLAR   ABSCESS. 

moval  of  the  tooth.  In  the  lower  teeth,  a  very  serious 
difficulty  occasionally  occurs  from  abscess,  namely,  an 
external  opening  and  discharge;  and  in  all  cases 
where  this  condition  has  already  been  reached,  the  of- 
fending tooth  should  he  removed.  But  when  such  a 
result  is  only  anticipated,  and  is  yet  contingent,  treat- 
ment may  be  employed  to  avert  it ;  and  in  order  to  do 
this,  a  deep  and  free  incision  should  be  made  in  the 
gum,  opposite  the  affected  tooth,  and  poultices  applied 
within ;  and  where  there  is  external  swelling,  pressure 
is  recommended,  as  follows :  Adjust  a  piece  of  thick 
sheet-lead  to  the  j>art,  and  make  the  pressure  on  this 
by  means  of  a  bandage  embracing  it  and  passing  round 
the  head.  It  is  supposed  that  this  application  coun- 
teracts the  gravitation  of  the  secretion,  pressing  it  up- 
ward, and  thus  inducing  it  to  seek  an  outlet  at  some 
more  desirable  point. 

In  many  cases  the  most  prompt  and  efficient  treat- 
ment consists  in  the  extraction  of  the  tooth  involved 
by  the  abscess.  This  should  be  carefully  done,  that 
there  may  be  no  fracture  of  the  alveolus,  and  no 
laceration  of  the  gum.  After  the  tooth  is  removed 
it  should  receive  the  following  treatment:  Remove 
from  the  root  or  roots,  with  the  proper  instrument,  all 
coagulated  lymph,  diseased  periosteum,  and  any  foreign 
substance  that  may  be  present.  The  cavity  of  decay, 
if  one  exists,  the  pulp-chamber,  and  canal  in  the  root 
or  roots,  should  all  be  perfectly  cleansed,  formed,  and 


TREATMENT   OF    ALVEOLAR   ABSCESS.  351 

filled  permanently.  This  will  occupy  from  thirty  to 
sixty  minutes.  This  part  of  the  work  should  proceed 
as  rapidly  as  is  consistent  with  thoroughness.  Imme- 
diately after  the  removal  of  the  tooth  there  should  be 
placed  in  the  socket  from  which  it  was  removed  a 
pledget  of  cotton,  moistened  with  some  preparation 
that  would  be  acceptable  to  the  part,  and  that  will 
jn-event,  so  far  as  may  be,  the  coagulation  of  the  blood 
while  the  tooth  is  out  of  the  socket.  For  this  pur- 
pose the  tincture  or  the  infusion  of  calendula  (mari- 
gold) has  been  used,  and  also  hamamelis  virginica 
(witch  hazel)  extract ;  both  of  these  have  been  used, 
with  good  results.  Some,  however,  prefer  to  use  noth- 
ing of  the  kind  for  this  purpose,  but  rather  permit  the 
blood  to  coagulate  in  the  socket,  and  remove  just  be- 
fore inserting  the  tooth. 

The  tooth  having  been  prepared  as  above  described, 
should  now  be  carefully  replaced  in  its  socket,  the 
jaws  should  then  be  closed  firmly,  which  will  carry  the 
tooth  to  its  precise  position.  Ordinarily,  no  stays  or 
ligatures  will  be  required  to  hold  it  in  position. 

Just  previous  to  the  replacement  the  pledget  of  cot- 
ton will  be  removed,  and  any  debris  that  may  be  found, 
clot-  of  blood,  and,  indeed,  any  and  every  thing  that 
does  not  properly  belong  to  the  part  as  living  struc- 
ture, should  be  t;iken  away.  Usually,  the  tooth  will 
become  firmly  attached  within  a  few  days.  This  mode 
of  treatment  is  practicable  even  when  a  fistulous  open- 


352  ALVEOLAE   ABSCESS. 

ing  has  been  formed  through  the  cheek  to  the  external 
surface. 

In  regard  to  the  treatment  of  alveolar  abscess, 
much  vet  remains  to  be  learned.  "With  the  attain- 
ments  thus  far  made  in  this  direction,  no  aspiring 
dentist  will  rest  satisfied,  though  in  the  hands  of  a 
few  it  has  made  great  progress  within  a  very  recent 
period. 

In  a  treatise  of  this  character  it  is  impracticable  to 
enter  into  the  details  of  the  pathology  of  this  affection, 
oi",  very  minutely  into  the  rationale  of  its  treatment. 
A  thorough  knowledge  of  these  involves  a  wide  range 
of  pathological  knowledge. 


CHAPTER  X. 

PIVOT     TEETH. 

Whenever  the  crowns  of  the  anterior  teeth  have 
become  so  much  decayed  that  they  cannot  by  filling 
be  rendered  useful,  they  may,  under  favorable  cir- 
cumstances, be  supplied  by  artificial  crowns  con- 
structed on  the  roots.  For  the  successful  accom- 
plishment of  this  work,  the  following  conditions  are 

important: 

First.   The  constitution  of  the  patient   should  be 

good. 

Second.  The  mouth  should  be  in  a  healthy  condi- 
tion and  without  diseased  teeth  or  roots. 

Third.  The  teeth  should  be  free  from  calcareous 
deposits,  and  from  all  foreign  substances  liable  to  in- 
duce irritation  or  inflammation. 

Fourth.  The  attachment  of  the  teeth  should  be 
perfed  and  healthy. 

Fifth.  A  root  having  a  living,  healthy  pulp  is  to  be 
preferred  to  one  the  pulp  of  which  has  been  dead  for 

-Mine  time. 

<ixth.  The  root  above  the  neck  should  be  sound. 
Seventh.  The  root  should  occupy  a  correct  position 

•r. 


354  PIVOT   TEETH. 

in  the  arch.  Prior  constitutional  treatment  will  often 
be  required  where  there  are  unfavorable  conditions. 

The  roots  of  the  six  superior  anterior  teeth  are 
better  adapted  for  the  reception  of  artificial  crowns 
than  those  of  any  other  in  the  mouth.  The  roots  of 
the  first  bicuspids  frequently  terminate  in  two  points, 
and  are  always  more  or  less  compressed,  so  that  they 
wTill  not  receive  a  pivot  large  enough  to  sustain  a 
crown;  besides,  these  teeth  are  masticatory,  and  crowns 
pivoted  to  them  very  soon  become  loose  and  useless. 
The  roots  of  the  inferior  incisors  are  also  compressed, 
and  thus  subject  to  the  same  disability.  Occasionally, 
how  ever,  pivot  crowns  are  attached  to  the  roots  of  the 
superior  bicuspids,  and  the  inferior  incisors,  cuspids, 
and  bicuspids.  But,  in  order  that  such  an  operation 
shall  be  of  any  utility,  the  conditions  must  be  favor- 
able, the  roots  with  as  little  lateral  compression  as  pos- 
sible, in  a  very  sound  and  healthy  state,  and  without 
any  tendency  to  inflammation. 

The  preparation  of  the  root  for  the  reception  of  an 
artificial  crown  is  a  very  simple  process.  It  will, 
however,  be  somewhat  modified  by  the  kind  of  crown 
used,  and  the  method  of  attaching  it.  Ordinarily, 
the  first  step  is  to  remove  the  natural  crown  or  any 
remaining  portion  of  it,  with  a  fine  saw  or  excising 
forceps.  Of  this  latter  instrument  there  are  various 
forms,  that  in  most  common  use  having  narrow  trans- 
verse edges,  closing  squarely  together,  as  represented 


PIVOT   TEETH.  355 

in  Fig.  97.  With  these  forceps  any  broken  fragments 
of  the  crown  can  be  readily  removed.  In  every  case 
in  which  an  artificial  crown  is  required,  the  natural 
crown  is  very  much  decayed,  and  in  this  condition  is 
very  readily  removed  with  excising  forceps,,  nipping  it 

Fig.  97. 


off  in  fragments,  beginning  where  it  is  weakest  and 
thinnest,  and  thus  removing  it  by  piecemeal — at  least 
as  far  as  the  forceps  are  available.  Yet  care  is  neces- 
sary, even  in  this  manner  of  using  the  forceps,  lest 
the  root  be  fractured  or  too  much  jarred. 

Fig.  98. 


After  such  excision  with  the  forceps,  the  loot  is  to 
be  dressed  down  for  the  reception  of  the  crown  with  a 
round,  or,  better,  an  elliptical  file.  But  for  this  opera- 
tion of  removing  a  crown  a  very  line,  smooth,  narrow 
.-aw,  set   in    a   frame   (Fig.  98),  is,  in   some   respects, 


356  PIVOT   TEETH. 

preferable  to  the  forceps,  it  being  less  liable  to  injure 
the  root  than  the  latter.  With  this  the  crown  is  sawed 
off  at  the  margin  of  the  gum,  leaving  the  end  of  the 
root  about  the  form  required  for  the  reception  of  the 
artificial  crown.  In  the  process,  the  crown  being  sus- 
tained by  the  fingers,  the  saw,  kept  constantly  wet,  is 
applied  to  the  tooth,  and  passed  along  its  proximate 
side  to  the  margin  of  the  gum,  and  then  along  this 
through  it,  cutting  it  off  at  right  angles  with  its  axis. 
After  the  crown  has  been  thus  cut  off,  the  root  is  fitted 
with  a  fine,  round  file  for  the  artificial  crown,  and,  or- 
dinarily, it  should  be  dressed  at  a  right  angle  with  its 
axis. 

At  this  stage  of  the  work,  if  the  pulp  remains  alive, 
it  should  be  removed,  and  the  preferable  method  is  by 
direct  operation,  in  the  manner  already  described  (pp. 
304-5) .  It  is  better  in  all  such  cases  to  avoid  the  use 
of  arsenic  for  the  destruction  of  the  pulp;  it  will  often 
be  necessary  to  destroy  it  before  the  crown  is  removed. 
For  a  successful  operation  it  is  always  preferable  that 
the  root  have  the  pulp  living.  After  it  is  removed, 
the  canal  is  to  be  enlarged  to  a  suitable  size,  with  the 
appropriate  drill.  If  there  is  any  remaining  sensi- 
tiveness of  the  dentine,  as  is  very  seldom  the  case,  the 
bur  drill  may  be  used  for  this  purpose;  but  if  not, 
then  the  common  spear-pointed  drill  will  be  best. 
Where,  however,  the  canal  takes  the  form  of  a  mere 
fissure,  either  the  bur  drill  or  the  four-sided  broach 


FITTING   THE    CROWN.  357 

may  be  employed.  The  depth  to  which  the  canal 
should  be  enlarged  will  be  determined  by  the  length 
of  the  root,  but  it  should,  in  all  cases,  be  sufficient 
firmly  to  retain  a  pivot,  which  is  from  one  to  two 
lines  ;  and  the  diameter  of  the  hole  will  be  determined 
by  the  size  of  the  root.  The  drills  should  be  frequently ' 
moistened  with  water  to  prevent  their  clogging.  The 
shaft  of  the  instrument  in  the  operation  should  be  in 
a  line  with  the  cutting  edges  of  the  two  adjoining 
teeth,  and  midway  between  them,  and  the  drill  it- 
self should  follow  the  natural  canal  as  nearly  as  pos- 
sible. 

Fitting  the  Crown. 

The  tooth  selected  should  be  of  a  size,  shape,  and 
color  to  correspond  with  the  natural  crown  which  it  is 
to  represent.  It  should  not  be  ground  on  the  sides  or 
point,  and,  according  to  general  opinion,  ought  not  to 
be  touched  with  the  emery-wheel.  A  different  opinion, 
however,  is  entertained  by  some,  who  suggest  the 
grinding  of  the  entire  anterior  surface  of  the  artificial 
crown,  thus  removing  the  vitrified  surface  of  the  en- 
amel, after  which  it  should  be  well  polished  with  fine 
stones  and  emery,  by  which  it  is  claimed  that  the  ap- 
pearance corresponds  much  better  with  that  of  the 
natura]  teeth,  which  In  many  cases,  at  least,  is  correct, 
The  diameter  of  the  neck  of  the  crown  should  corre- 
spond with  that  of  the  articulating  surface  of  the  root 


358  PIVOT   TEETH. 

to  which  it  is  to  be  attached.  In  fitting  the  crown  to 
the  rool  thejoinl  should  be  made  as  nearly  perfect  as 
possible,  for  the  tooth  is  thus  more.'  permanent  and 
comfortable ;  an  open  joint  offers  a  receptacle  for  the 
lodgment  of*  food  and  other  foreign  substances,  where 
they  become  vitiated  and  produce  unpleasant  if  not  in- 
jurious effects.  The  crown  may  be  principally  fitted 
to  the  root  without  a  pivot  by  dressing  the  latter  with 
a  round  or  elliptical  file,  and  frequently  trying  the 
crown  on  in  its  proper  position.  After  having  been 
thus  pretty  accurately  fitted,  a  trying  pivot  of  soft 
wood  should  be  introduced,  by  means  of  which,  grind- 
ing it  to  its  exact  form,  the  crown  may  be  fitted  to  the 
root  in  its  proper  position. 

For  fitting  pivot  teeth  Dr.  E.  Townsend  invented 
a  round  file,  with  a  counterpart,  into  which  the  file 
exactly  fits;  with  the  former  of  these  the  root  is 
dressed,  and  with  the  latter  the  articulating  surface 
of  the  crown.  This  apparatus  would  be  good  were  it 
not  for  the  great  difficulty  of  dressing  porcelain  teeth 
with  a  file.  By  care,  a.  very  complete  fit  can  be  made 
with  a  round  file  alone.  Some  coloring  material,  as 
rose  pink,  for  instance,  may  be  put  on  the  base  of  the 
crown,  and  then  the  tooth,  with  the  pivot  inserted, 
set  in  its  place,  when  the  root  will  be  marked  where 
the  crown  has  touched  it,  and  this  can  be  dressed 
at  the  point  of  contact.  This  operation  is  repeated 
till  a  perfect  fit  is  obtained.     This  method  is  to  be 


ATTACHMENT   OF   THE   CROWN.  359 

recommended  to  those  who  have  had  but  little   ex- 
perience in  adjusting  pivot  teeth. 

Another  method  of  making  an  articulation  is,  to 
dress  the  root  as  first  described,  then  take  an  impres- 
sion of  the  part  in  plaster  of  Paris,  and  from  this  get 
a  model  upon  which  to  fit  the  crown.  This  method, 
however  is  advisable  only  in  cases  where  it  is  desirable 
to  avoid  annoyance  to  the  patient  by  a  tedious  fitting 
process. 

Attachment  of  the  Crown. 

The  means  of  attachment  in  most  common  use,  till 
recently  at  least,  is  that  of  wood  pivots;  for  these 
wood  in  the  natural  condition  was  formerly  employed, 
but  it  is  now  compressed.  The  kind  best  adapted  for 
pivots  is  the  fine-grain,  tough,  slow-growth  hickory, 
of  straight,  uniform  fibre,  which  should  be  thoroughly 
seasoned.  For  its  preparation,  take  blocks  six  or  eight 
inches  long,  and  split  them  into  rods -about  one-fourth 
of  an  inch  square ;  then,  with  a  knife  and  file  dress 
them  down  to  a  size  one-third  greater  than  that  of  the 
intended  pivots;  afterward,  pass  them  through  three 
or  four  holes  of  the  ordinary  drawplate  inverted,  thus 
making  them  of  uniform  thickness  throughout;  and, 
finally,  turning  the  drawplate,  pass  them  through  it  in 
the  same  manner  as  wire,  continuing  till  the  rods  are 
of  proper  size,  and  all  the  pores  of  the  wood  are  closed 
by  compression.     They  should  be  slightly  oiled  before 


360  PIVOT   TEETH. 

being  drawn  through  the  plate.  They  may  be  drawn 
so  as  just  to  lit  the  holes  of  the  artificial  crowns,  being, 
of  course,  of  different  sizes.  Pivots  thus  compr< 
are  stiffer,  stronger,  and  far  more  durable,  and  there 
being  greater  density  of  fibre  there  is  less  absorption 
of  moisture,  less  expansion,  and  less  liability  to  decay 
than  in  wood  in  the  natural  condition. 

In  arranging  the  crown  in  position,  care  is  necessary 
t< » ]  >revent  it  from  being  struck  by  the  teeth  of  the  oppos- 
ing jaw,  especially,  since  it  often  happens,  where  the 
natural  crown  has  been  absent  for  some  time,  that  the 
corresponding  tooth  of  the  lower  jaw  becomes  some- 
what elongated,  and  strikes  forcibly  against  a  properly 
adjusted  pivot  tooth.  Such  a  difficulty  is  met  either 
by  filing  off  the  elongated  tooth,  or,  by  grinding  out 
the  palatal  portion  of  the  artificial  crown  sufficiently 
to  accommodate  the  elongation.  The  former  is  the 
better  method,  and  should  always  be  adopted  when  in- 
flammation of  the  dentine,  exposure  of  the  pulp,  or  an 
irritable  condition  of  the  surrounding  parts  do  not 
forbid  it;  though,  in  many  instances,  both  methods 
may  be  advantageously  employed.  But,  by  some  means, 
the  antagonizing  teeth  should  always  be  prevented 
from  coming  in  contact  with  the  artificial  crown;  and 
this  latter  should  never  press  against  the  tooth  on 
either  side  of  it ;  indeed,  it  is  better  that  there  be  a 
small  space  on  each  side. 

When  the  crown  is  in  its  proper  position,  the  hole 


ATTACHMENT   OF   THE   CROWN.  361 

in  the  root  and  that  in  the  crown  do  not  always  have 
precisely  the  same  direction  ;  in  which  case,  a  pivot 
will  be  required  having  a  curvature  according  to  the 
variation  ;  and  the  extent  and  direction  of  such  inflec- 
tion should  be  carefully  observed  while  adjusting  the 
crown  with  the  trying  pivot.  The  pivot  is  to  be  neatly 
and  accurately  fitted  into  the  crown  first,  and  then  the 
length  of  it  required  for  the  root  ascertained  with  the 

Fig.  99. 


gauge  represented  in  Fig.  99.  This  gauge  consists 
of  a  wire  of  a  size  freely  to  enter  the  pivot-hole,  hav- 
ing a  little  slide  with  a  flange  attached.  By  introdu- 
cing this  wire  into  the  pivot-hole,  the  slide  is  pressed 
back,  and  the  depth  of  the  hole  indicated  at  once.  The 
pivot  is  then  cut  off  accordingly  and  dressed  to  the 
proper  size  and  inclination,  and  gently  pressed  to  its 
place  with  the  thumb  and  finger.  Before  being  intro- 
duced, however,  it  may  be  wrapped  with  gold  foil, 
which  will  serve  to  protect  the  dentine  of  the  root  from 
decay,  and  also  to  preserve  the  pivot.  Two  or  three 
thicknesses  of  No.  6  gold  foil  may  be  placed  between 
the  ciow n  ;md  the  root,  so  as  to  make  a  more  perfect 
joint  and  exclude  the  moisture.  There  is,  however, 
not  much  advantage  in  this.  A  thin  sheet  of  Hill's 
Btopping,  placed  in  the  joint,  makes  a  better  adaptation 


362  PIVOT   TEETH. 

than  the  gold,  and  os  artificial  may  be  used  for  the 
same  purpose,  and  in  many  instances  is  far  better  than 
either  Hill's  stopping  or  gold  ;  the  canal  in  the  root 
above  the  pivot  should  be  filled  with  gold,  or  some 
appropriate  material,  though  in  cases  where  there  is  a 
discharge  through  the  root,  this  would  not  be  admis- 
sible. 

The  canal  at  the  orifice  is  sometimes  considerably 
enlarged  by  decay,  so  that  when  the  crown  is  fitted 
and  the  canal  sufficiently  opened  for  the  reception  of 
the  pivot,  there  will  be  a  cone-shaped  space  which  the 
ordinary  pivot  will  not  fill.  There  are  several  methods 
of  obviating  this  difficulty  ;  one  of  these  is,  completely 
to  fill  the  enlargement  with  gold,  and  then  perforate 
this  filling  with  the  proper-sized  drill  for  the  reception 
of  the  pivot ;  or,  which  is  better,  to  introduce  into  the 
canal  a  polished  steel  wire  of  the  size  of  the  intended 
pivot ;  round  this  consolidate  a  filling  of  gold,  having 
first  made  retaining-points  at  the  proper  places  in  the 
dentine  ;  finish  perfectly  flush  with  the  end  of  the 
root ;  and  then  withdraw  the  wire  from  the  canal,  and 
it  is  ready  to  receive  the  pivot  with  the  crown  attached. 
Some  operators  form  the  wood  pivot  of  such  a  shape 
as  to  fit  into  and  fill  the  enlarged  cavity.  Another 
method  is,  after  the  pivot  is  fastened  into  the  crown, 
to  build  round  it,  on  the  base  of  this,  a  portion  of 
Hill's  stopping,  of  about  the  size  and  form  of  the  en- 
largement in   the  canal ;  and  then  the  tooth  being 


METALLIC   PIVOTS.  363 

ready  to  insert,  soften  the  stopping  by  heat,  and  in- 
troduce it  carefully  into  place.  The  os  artificial  in 
such  cases  is  still  better. 

It  frequently  happens,  in  cases  where  the  pulp  has 
been  dead  for  a  considerable  time,  that  there  is  more 
or  less  discharge  through  the  canal  of  the  root,  and  a 
tooth  is  required  immediately,  or  at  least  before  there 
is  time  for  treatment  to  abate  the  discharge.  To 
such  a  condition  some  arrangement  must  be  adapted 
so  as  not  entirely  to  close  up  the  canal,  and  preclude 
the  escape  of  pus.  For  this  purpose  a  groove  may  be 
cut  along  the  wall  of  the  canal,  or,  perhaps  better,  on 
the  side  of  the  pivot  throughout  its  length,  for  the  dis- 
charge of  the  secretion.  Where  there  is  irritation  or 
liability  to  inflammation,  a  temporary  pivot  of  soft  wood 
or  of  hard  wood  loosely  fitted,  should  be  worn  ;  for  thus 
the  root  is  less  jarred  by  percussion  on  the  crown,  and, 
if  need  be,  the  crown  and  pivot  can  be  removed. 

Metallic  Pivots. 

The  liability  of  a  pivot  of  wood  to  wear  ofF  at  the 
point  between  the  crown  and  the  root,  as  well  as  to  be- 
come offensive,  and  the  difficulty  of  removing  the  tooth, 
have  led  dentists  to  seek  some  less  objectionable  mate- 
rial ;  and  metals  have  been  experimented  upon,  and 
found  in  some  respects  preferable.  Gold  has  been  em- 
ployed for  this  purpose  more  than  any  other  metal. 


364  PIVOT   TEETH. 

Pivots  made  of  this  do  not  become  offensive,  do  not 
uc.tr  off,  and  admit  of  any  desired  curve,  and  of  an 
easy  removal  of  the  crown.     There  are  several  methods 
of  attaching  this  kind  of  pivot  to  a  tooth,  and  a  very 
common  one  is,  to  fit  into  the  hole  in  the  crown  a  piece 
of  pivot  wood ;  cut  it  off  even  with  the  base  of  the 
crown,  and  perforate  it  with  the  proper-sized  drill  for 
the  reception  of  the  metal  pivot,  which  may  be  rough- 
ened or  barbed  on  its  sides,  and  then  forced  into  the 
place  prepared  for  it.    Another  method  is  to  drill  into 
a  block  of  wood  ;  insert  the  pivot,  prepared  as  above, 
then  dress  down  the  wood  round  it  till  this  will  fit 
closely  into  the  crown  ;  and  after  it  is  pressed  in,  cut 
off  the  protruding  rjortion  of  wood.    In  either  of  these 
methods,  when  the  wood  becomes  moist,  the  metal  pivot 
will  be  very  firmly  retained.     This  pivot  may  also  be 
attached  to  the  crown  by  soldering.     Place  the  edge 
of  the  tooth  in  plaster  of  Paris ;  set  the  pivot  in  its 
proper  position  in  it ;  fill  round  this  with  fragments 
of  gold  plate,  and  put  on  solder  and  borax ;  heat  up 
with  a  blow-pipe,  and  draw  the  solder  to  the  bottom 
of  the   cavity.     Another    method,    sufficient   for   all 
practical  purposes,  is  to  set  the  pivot  in  place,  and 
pack  round  it  a  stiff  amalgam  of  gold  and  mercury  ; 
evaporate  the  mercury  by  heat.     A  better  method 
than  any  of  these  is  to  have  teeth  manufactured  with 
a  platinum  tube  inserted,  into  which  the  pivot  can  be 


METALLIC   PIVOTS.  365 

soldered.  Pivots  may  also  be  attached  to  the  ordinary 
plate  teeth. 

For  attaching  the  metal  pivot  to  the  root,  it  is  some- 
times fitted  tightly  to  the  canal,  and  introduced  into 
it  without  any  other  substance.  This  is  objectionable 
on  account  of  the  wearing  of  the  root,  certain  to  take 
place  if  there  is  the  least  jarring  or  moving  of  the 
crown.  To  obviate  this,  various  methods  have  been 
devised,  one  of  which  is  to  wind  floss  silk  about  the 
pivot  before  introducing  it ;  but  this  soon  becomes  of- 
fensive, and  requires  frequent  renewal.  Another  me- 
thod is  to  introduce  a  piece  of  wood  into  the  root,  and 
drill  through  it  for  the  reception  of  the  pivot,  which 
is  squared  and  roughened, — squared  to  prevent  it  from 
turning  round,  and  roughened  to  secure  it  from  draw- 
ing out.  But  if  it  is  desirable  to  remove  the  tooth 
occasionally,  the  pivot  should  not  be  barbed. 

Metal  tubes  may  be  introduced  into  the  roots  for  the 
reception  of  the  pivots.  These  tubes  are  made  of  hol- 
low gohl  wire  of  proper  size,  the  method  of  j)repar- 
ing  which  is,  to  take  a  piece  of  No.  30  gold  plate, 
from  four  to  six  inches  long,  and  from  a  third  to  a 
half  inch  wide,  and  bend  it  round  a  piece  of  smooth 
polished  steel  wire  of  the  size  of  the  intended  pivot; 
draw  both  together  through  a  drawplate,  down  to  one 
Bize  larger  than  the  hole  in  the  root;  then  take  out 
the  wire,  and  solder  up  the  tube ;  on  it  cut  a  fine 
thread   with  a  screw-plate;  from  it  cut  off  a  half  to 


366  PIVOT  TEETH. 

three  fourths  of  an  inch  in  length,  and  insert  into 
this  a  piece  of  wire  it  was  drawn  upon ;  grasping 
this  section  with  a  small  vice  or  pair  of  nippers,  screw 
it  carefully  into  the  root ;  and  having  introduced  it 
far  enough,  withdraw  the  piece  of  wire,  cut  off  the 
protruding  piece  of  tube  with  a  fine  saw  then  file  and 
neatly  polish.  The  root  is  thus  ready  for  the  recep- 
tion of  the  crown,  the  pivot  of  which  should  fit  very 
accurately  into  the  tube.  A  very  slight  curvature  of 
the  pivot  will  enable  it  to  retain  a  very  firm  hold  in 
the  tube.  The  tube's  inner  end  may  be  soldered  up 
if  desirable;  and  if  there  is  decay  at  the  orifice  of 
the  canal,  a  flange  may  be  soldered  on  to  its  outer  end, 
flush  with  the  end  of  the  root,  and  the  decayed  cav- 
ity filled  beneath  it,  the  flange  serving  to  retain  the 
filling  perfectly  in  place.  These  tubes  can  be  best  fit- 
ted in  with  the  screw,  though  they  are  sometimes 
placed  in  without  this,  and  gold  foil  packed  about 
them  to  retain  them.  They  may  be  made  to  receive  a 
square  pivot,  by  being  drawn,  in  their  manufacture, 
on  a  square  wire  instead  of  a  round  one.  For  the  es- 
cape of  ])us,  as  already  referred  to,  the  j)ivot  may  be 
made  of  hollow  wire,  with  a  hole  through  the  crown 
of  the  tooth. 

A  plate  tooth,  with  a  metallic  pivot  attached,  may 
be  used  instead  of  the  ordinary  pivot  tooth ;  and  it 
is  in  some  cases  required,  on  account  of  the  manner 
in  which  the  teeth  antagonize.    But  in  all  cases  where 


METALLIC  PIVOTS.  367 

a  plate  tooth  is  used,  it  should  have  a  metallic  base  to 
rest  on,  and  cover  the  end  of  the  root.  Properly  to 
construct  this,  an  impression  must  be  obtained,  and 
models  and  counter-models  made,  and  the  base  swaged; 
and  then  to  this  the  pivot  and  tooth  are  attached. 
Irregularity  of  the  teeth,  and  especially  of  the  root 
on  which  the  crown  is  to  rest,  may  require  a  peculiar 
adjustment  of  the  pivot,  which  may  be  very  easily 
effected  by  the  method  just  referred  to. 

Occasionally,  bad  consequences  follow  the  opera- 
tion of  inserting  a  pivot  tooth,  the  most  frequent  of 
which  is  inflammation  of  the  periosteum.  Rough 
manipulation  is-  very  liable  to  induce  this  condition, 
where  there  is  an  inflammatory  diathesis,  in  which 
case  too  great  care  cannot  be  recommended;  and 
prior  treatment  will  sometimes  be  advantageous.  After 
periostitis  has  supervened,  either  constitutional  or  local 
treatment,  or  both  may  be  employed, — constitutional, 
by  emetics  and  saline  cathartics,  and,  indeed,  any  agent 
that  will  equalize  the  circulation  and  counteract  the 
inllammation  ;  and  local,  by  the  same  means  as  already 
prescribed  for  periostitis  elsewhere;  in  addition  to 
which,  it  may  sometimes  be  necessary  to  remove  the 
crown  and  pivot  from  the  root.  It  is  always  impor- 
tant to  commence  the  treatment  of  such  cases  at  the 
first  indications  of  the  disease 

Sometimes,  even  with  considerable  care,  a  crown 
will  be  —  j > I i t  by  the  introduction  or  the  expansion  of 


308  PIVOT   TEETH. 

the  pivot,  in  which  cane,  of  course,  another  tooth  must 
be  selected.  When  a  pivot  breaks  off,  and  a  portion 
adheres  in  the  root,  this  may  be  drawn  out  with  pliers, 
or  a  pivot  extractor,  or,  if  it  does  not  protrude  enough 
for  this,  it  may  be  drilled  out.  A  root  is  sometimes 
split  by  the  expansion  of  a  tightly-fitting  pivot,  or  by 
a  blow  on  the  crown  of  the  tooth ;  and  when  this  hap- 
pens, it  must  be  removed,  since  it  cannot  be  made 
longer  to  retain  a  tooth.  Pivot  teeth  should  seldom, 
if  ever,  be  worn  in  a  mouth  in  which  teeth  on  plate 
are  worn.  They  are  now  far  less  frequently  worn 
than  formerly,  because,  perhaps,  of  the  improved  me- 
thod of  inserting  teeth  on  plate.  Under  favorable 
circumstances,  however,  they  may  be  worn  with  great 
comfort  and  usefulness  from  five  to  fifteen  years. 

Other  methods  of  making  and  attaching  substitutes 
for  the  crowns  of  the  natural  teeth  have  been  devised 
and  brought  into  quite  general  use  since  the  third  edi- 
tion of  this  work  was  issued. 

These  have  greatly  increased  the  range  of  useful- 
ness of  artificial  crowns.  They  are  constructed  and 
applied  with  about  equal  facility  to  the  roots  of  all 
classes  of  teeth,  thus  making  the  roots  of  much  more 
importance  and  value  than  they  were  formerly  sup- 
posed to  possess. 

Considering  the  use  which  they  may  now  be  made  to 
serve,  it  may  wellnigh  be  regarded  as  criminal  to  ex- 
tract sound  healthy  roots. 


METALLIC   CROWNS.  369 

The  first  plan  of  restoration  to  which  reference  is 
now  made,  is  that  denominated  the  "Richmond  crown," 
from  the  name  of  him  who  claims  to  have  invented  it. 
The  plan  consists  in  the  construction  of  a  gold  crown 
in  about  the  following  manner:  From  plate,  if  gold, 
twenty-two  carats  fine,  and  in  thickness  about  thirty, 
Stub's  gauge,  cut  a  band  or  strip  equal  in  width  to 
the  length  of  the  proposed  crown  ;  then  get  the  exact 
circumference  of  the  cervical  part  of  the  root  upon 
which  the  crown  is  to  be  placed ;  then  make  the  gold 
band  to  correspond  in  length  to  the  circumference  al- 
ready obtained,  and  bend  it  into  a  ring,  shaping  it  as 
nearly  to  the  form  of  the  end  of  the  root  as  may  be ; 
place  the  ends  squarely  together  and  solder;  then 
adapt  and  fit  to  the  end  of  the  root,  so  it  may  be 
pressed  or  driven  on  and  retain  its 'position  with  a  good 
degree  of  fixedness.  Now  remove  the  band  and  solder 
upon  its  crown  end  a  heavy  plate;  upon  this  should 
be  solclered  three  or  four  little  globules  of  gold,  if  for 
a  molar,  or  if  a  bicusjnd,  two,  to  constitute  the  cusps 
of  the  crown.  The  crown  surface  thus  formed  can  be 
trimmed  and  dressed  with  the  burs  and  corundum 
cones  to  any  particular  form  indicated.  A  better 
method  of  preparing  the  crown  plate  is  to  use  pure 
gold  plate,  No.  30,  Stub's  gauge;  then,  with  dies  made 
from  tin'  impressions  of  well-formed  teeth  of  the  same 
class,  stamp  tin;  plate,  giving  it  the  exact  form  of  the 
masticating  surface  of  a  natural  tooth  of  the  class  in 

24 


370  PIVOT  TEETH. 

hand.  This  cap  should  have  its  inner  depressions 
filled  with  fine  gold  Bolder,  then  fit  and  solder  the  car) 
to  the  band  already  described,  and  proceed  with  the 
insertion  as  by  the  other  plan.  Having  the  crown 
thus  formed,  it  is  ready  for  insertion.  The  root  is 
next  to  be  prepared,  if  not  already  done ;  indeed, 
in  most  cases,  where  circumstances  will  permit,  it  is 
proper,  and  perhaps  best,  to  first  prepare  the  root.  If 
this  has  irritation  or  disease  about  it,  or  a  discharge 
through  it,  restoration  to  a  healthy  condition  must 
first  be  effected,  and  especially  if  there  is  discharge 
through  the  root  must  it  be  arrested.  After  these 
things  are  accomplished,  any  protruding  portions  of 
the  root  that  would  prevent  the  proper  adjustment 
of  the  crown  should  be  removed ;  the  canal  should 
be  thoroughly  cleansed,  disinfected,  and  the  remote  or 
inner  third,  or  even  half,  of  the  canal  completely  filled 
with  some  appropriate  material.  Suggestions  upon 
this  subject  given  on  page  362  of  this  work  are*  perti- 
nent here.  Into  the  outer  and  unfilled  part  of  the  canal 
may  be  fixed  a  screw;  this  may  be  of  gold,  platinum, 
or  steel ;  the  latter,  in  some  respects,  is  better  than 
either  of  the  others ;  it  can  be  obtained  already  made, 
of  the  right  size  and  form,  and  is  stronger  than  either 
gold  or  platinum.  The  screw,  when  fixed  in  place, 
should  be  of  such  size  and  length  as  to  admit  the 
crown  to  its  proper  position.  The  next  and  final  step 
in  the  work,  if  all  things  have  been  well  done  to  this 


METALLIC  CROWXS.  371 

point,  is  to  place  on  the  end  of  the  root,  about  the 
screw,  a  small  portion  of  oxyphosphate  or  oxychloride 
of  zinc,  and  a  sufficient  amount  in  the  crown  that  the 
space  is  completely  occupied  when  the  crown  is  forced 
to  its  proper  place.  It  is  not  always  an  easy  matter  to 
decide  as  to  the  requisite  amount  of  plastic  material; 
too  small  a  quantity  will  occasion  a  space  beneath  the 
crown,  and  endanger  the  strength  and  permanence 
of  the  work,  and  an  excess  will  prevent  the  crown  from 
taking  its  proper  position.  To  meet  this  difficulty  the 
practice  of  some  is  to  drill  a  hole  through  the  crown- 
surface  of  the  tooth  sufficient  in  size  for  the  escape  of 
the  excess  of  the  plastic  filling,  always  using  enough  to 
certainly  fill  the  space,  and  afterward  filling  the  hole 
with  gold  foil  or  with  a  screw.  The  crown  should  be 
finished,  and  its  adaptation  made  to  the  tooth  of  the 
opposite  jaw,  before  the  final  setting.  They  may  be 
made  of  gold  or  platinum. 

Another  method  is,  after  having  prepared  the  root 
as  described  above,  to  put  the  ring  or  band,  without  its 
crown  cap,  firmly  on  the  root,  and  fill  completely  with 
the  plastic  filling ;  after  this  has  become  perfectly  hard- 
ened, it  may  be  cut  down  and  formed  properly,  and 
tlx;  masticating  surface  made  by  filling  and  building 
with  gold  foil. 

Another  plan  is  to  form  the  crown  cap  as  described, 
and,  after  fitting,  instead  of  soldering  it  to  the  band, 
-older  to  its  inner  side  one  or  two  little  staples,  loops, 


372  PIVOT   TEETH. 

or  pins,  that  shall  serve  as  anchorages,  then,  when 
the  plastic  material  is  introduced  and  still  soft,  place 
the  cap  in  its  position  with  the  anchorage  loops  well 
imbedded  in  the  plastic  filling ;  after  this  has  set 
the  operation  is  about  complete,  except,  perhaps,  a 
little  dressing  and  finishing.  In  all  cases  the  border 
of  the  band  that  passes  beneath  the  free  margin  of 
the  gum  should  be  brought  to  a  thin  edge  before  it  is 
put  on,  and  when  in  place  should  fit  the  root  very  per- 
fectly ;  it  should  also  extend  nearly  or  quite  to  the 
line  of  attachment  of  the  gum  to  the  root. 

These  crowns  of  gold,  though  practicable  for  the 
molars,  and,  in  many  cases,  the  second  bicuspid,  and, 
in  a  few  cases,  for  the  first  bicuspid,  are  not  admissible 
for  the  six  anterior  teeth,  either  superior  or  inferior. 
But  the  principle  is  applicable  for  these,  the  process 
being  about  the  same  as  that  described,  except  that  a 
porcelain  facing,  representing  the  external  face  of  the 
tooth,  is  set  into  the  band,  which  is  cut  away  for  its 
reception  and  adaptation  to  the  root;  an  ordinary  thin, 
plain  plate  tooth  serves  the  purpose  well.  After  being 
properly  adjusted,  it  should  be  lined  and  soldered 
firmly  to  the  band,  the  two  thus  joined  constituting 
the  crown  to  be  inserted.  The  palatine  part  may  be 
covered  with  gold,  and  formed  to  the  shape  of  the 
palatine  surface  of  the  natural  tooth.  The  crown  thus 
formed  may  be  attached  as  already  described. 

The  root  for  the  reception  of  such  a  crown  should 


METALLIC   CROWNS.  373 

be  prepared  as  for  the  reception  of  a  molar  crown. 
The  details  in  the  insertion  of  these  crowns  has  varied 
somewhat  in  the  hands  of  different  operators,  but  the 
aim  has  been  in  this  description  to  so  present  the  prin- 
ciples that  any  well-qualified  j>ractitioner  would  have 
no  difficulty  in  executing  the  work  in  an  acceptable 
and  permanent  manner. 


CHAPTER  XL 


EXTRACTION     OF    TEETH. 


GENERAL   REMARKS. 


The  extraction  of  teeth  is  an  important  operation, 
requiring  for  its  proper  performance  skill,  judgment, 
and  experience,  as  well  as  an  accurate  knowledge  of 
the  parts  involved.  Success  in  the  operation  formerly 
was  very  uncertain ;  but  now,  from  an  increase  of 
knowledge  in  the  art  of  dental  surgery,  and  from 
great  improvements  in  the  instruments  employed,  the 
operation  is  generally  attended  with  success.  The  an- 
cients were  not  strangers  to  this  operation,  as  is  evi- 
denced by  relics  found  in  ancient  tombs,  with  teeth 
absent,  under  such  circumstances  as  to  warrant  the 
conclusion  that  they  were  removed  by  the  surgeon. 
Extracting  instruments  of  very  ancient  date  have 
also  been  found ;  and  ancient  writers,  too,  refer  to  the 
operation  as  one  not  much  more  pleasant  then  than 
now.  The  demand  for  this  operation  arises  not  from 
fancy,  fashion,  or  caprice,  but  from  dire  necessity — 
a  necessity,  too,  of  great  frequency.  Very  few  indi- 
viduals in  this  country  arrive  at  mature  age  without 
being  required  to  submit  to  it ;  and,  indeed,  the  ma- 


EXTRACTION    OF   TEETH.  375 

jority,  before  middle  age,  lose  in  this  manner  from 
four  to  ten  teeth,  and  many,  all.  The  following  are 
some  of  the  objects  for  which  a  resort  is  had  to  this 
operation  : 

1.  To  obtain  relief  from  pain,  caused  either  by  dis- 
ease of  the  pulp,  by  inflammation  of  the  periosteum, 
or  by  any  other  affection  involving  the  teeth,  that  can- 
not be  readily  controlled  without  their  removal. 

2.  To  prevent  pain  in  future.  This  of  course,  has 
reference  only  to  those  teeth  which  are  very  much  de- 
cayed, or  rendered  useless  by  any  cause,  and  which  are 
liable  at  any  time  to  occasion  disease  in  the  parts  about 
them. 

3.  To  save  sound  teeth  from  the  attack  and  ravage 
of  decay.  This  implies  those  teeth  which,  by  their 
offensive  condition,  would  prove  injurious  to  healthy 
teeth. 

4.  To  relieve  a  diseased  condition  of  the  contigu- 
ous parts,  such  as  alveolar  abscess,  neuralgia  excited 
by  dental  irritation,  diseased  antrum — and  sometimes, 
indeed,  remote  parts,  which  are  in  many  instances  af- 
fected by  diseased  teeth. 

5.  To  anticipate  and  obviate  irregularity.  There 
are  some  cases,  in  which  all  the  teeth  cannot  be  accom- 
modated with  a  proper  position  in  the  arch,  and  in 
which  the  removal  of  one  or  more  of  them  for  this 
purpose  becomes  a  necessity,  if  regularity  and  symme- 
t  rv  are  to  be  secured. 


376  EXTRACTION   OF   TEETH. 

6.  To  prepare  the  mouth  for  the  reception  of  arti- 
ficial dentures ;  though  these  are  sometimes  inserted, 
with  the  roots  of  the  teeth  remaining,  which  is  admis- 
sible only  when  the  roots  and  parts  about  them  are 
healthy  ;  otherwise  they  should  be  removed. 

Before  anything  else  is  done,  every  case  presented 
should  be  carefully  examined,  in  order  to  ascertain 
all  the  circumstances  and  conditions  that  might  in 
any  way  affect  the  operation.  It  is  important  to  ar- 
rive at  a  correct  conclusion  in  regard  to  the  tooth  or 
teeth  to  be  removed  ;  the  number  of  roots,  their  in- 
clination, and  the  character  of  their  attachment ;  in 
what  manner,  and  to  what  extent,  the  surrounding 
parts  will  be  affected  by  their  removal ;  and  the  prob- 
able amount  of  force  necessary  for  this  purpose.  The 
operator  will  in  many  instances  be  referred  to  the 
wrong  tooth  ;  for  a  sound  and  healthy  one  is  sometimes 
painful  from  sympatlw,  and  standing  in  contact  with 
a  decayed  and  painful  tooth,  makes  it  frequently  diffi- 
cult for  the  patient  to  determine  in  which  the  pain 
exists ;  and  sometimes  difficult  for  the  operator,  too, 
especially  where  the  decay  is  on  a  proximate  portion 
of  the  tooth,  and  not  easy  of  approach.  In  all  such 
cases,  great  care  should  be  exercised,  and  a  thorough 
examination  made.  There  is  often  extensive  decay 
on  the  proximate  side  of  the  tooth,  that  is  not  appar- 
ent at  first  view. 

The  constitution  is  also  to  be  noted — its  peculiarities, 


GENERAL    REMARKS.  377 

tendencies,  and  susceptibilities ;  as  these  will  often 
modify  the  operation.  A  highly  nervous  temperament 
will  not  endure  an  operation  that  one  of  a  different 
character  will  undergo  with  impunity.  There  may 
also  be  idiosyncrasies  and  conditions  that  will  forbid 
the  extraction  of  a  tooth.  One  of  these,  and  not  the 
least  formidable,  is  a  hemorrhagic  diathesis. 

The  manner  of  performing  the  operation  is  an  im- 
portant consideration  :  it  should  not  be  precipitate  or 
hurried.  A  very  good  criterion  is,  that  the  eye  should 
critically  follow,  and  the  mind  attentively  comprehend, 
every  movement  of  the  hand  and  instrument.  It  is  a 
very  common  method  to  seize  the  tooth,  turn  away  or 
shut  the  eyes,  and  make  the  most  rapid  motions  possi- 
ble, regardless  of  consequences.  Accidents,  such  as 
breaking  the  tooth,  fracturing  the  alveolus,  laceration 
of  the  soft  parts,  and  rupture  of  the  bloodvessels,  are 
very  liable  to  follow  a  hurried  execution ;  and  there 
are  many  cases  on  record  in  which  injury  has  resulted 
from  a  rapid  application  of  force  in  the  extraction  of 
teeth.  The  ancients  were  cautious  in  this  particular  : 
it  is  recorded  of  them  that  they  made  extracting  in- 
struments of  lead,  to  prevent  injury  from  the  employ- 
ment of  too  great  force.  It  is.  difficult,  always  to  de- 
termine the  exact  amount  of  force  that  may  be  neces- 
sary for  the  removal  of  a  tooth  in  any  given  case ; 
though  by  long  and  close  observation,  it  may  be  pretty 
accurately  calculated  ;  and  it  is  important  for  the  ope- 


378  EXTRACTION    OF   TEETH. 

rator  to  know  this,  so  as  to  prepare  for  the  emergency, 
and  to  select  the  instrument  appropriate  to  the  occasion. 
In  order  to  be  successful,  an  operator  must  be  confident 
of  his  ability,  and  to  be  so,  he  must  possess  it.  He 
should  be  familiar  with  the  anatomical  structure  of  the 
parts  to  be  operated  upon  :  should  understand  the 
physiological  and  pathological  conditions  of  the  parts 
adjacent;  and  should  properly  appreciate  their  influ- 
ence on,  and  their  connection  with,  the  teeth. 

There  is  a  great  difference  in  teeth  with  regard  to 
their  facility  of  removal.  Those  most  difficult  to  ex- 
tract possess  the  following  peculiarities  :  shortness  and 
thickness  of  crown;  in  the  incisors,  thickness — the 
edges  of  the  superior  and  the  inferior  meeting  squarely 
on,  or  deviating  but  little  from  their  points;  freedom 
from  prominences  on  the  crowns  of  the  molars  and 
bicuspids,  their  masticating  surfaces  being  smooth ; 
regularity  in  arrangement,  all  being  in  correct  position 
and  in  contact  with  one  another  ;  color  slightly  yellow  ; 
denseness  and  thickness  of  alveolus;  unyielding  firm- 
ness of  the  soft  tissue ;  lack  of  prominences  on  the 
gums  to  indicate  the  size  and  position  of  the  roots. 
Another  class  of  teeth,  differing  in  characteristics  from 
those  of  the  above,  are  also  very  difficult  of  extraction, 
namely  :  those  having  crowns  of  medium  length  and 
of  a  diameter  at  the  neck  much  less  than  at  the  mas- 
ticating surface ;  roots  long  and  divergent,  and  in  some 
cases  considerably  curved  ;  and  often  a  very  firm  union 


GENERAL   REMARKS.  379 

with  the  alveolus,  so  that  a  portion  remains  adhering 
to  the  tooth  when  it  is  extracted,  which  occurs  more 
frequently  with  the  superior  cuspid  teeth  than  with 
any  others  ;  and  often  the  septum  between  the  roots  is 
so  firmly  embraced  by  them,  especially  when  they  con- 
verge, that  it  is  brought  away  with  the  tooth  on  its 
extraction.  Bony  union  of  the  teeth  has  been  enu- 
merated as  one  of  the  occasional  obstacles  in  extraction 
of  the  teeth  ;  but  this  rarely  if  ever  occurs — the  mode 
of  development  almost  precluding  the  possibility  of  its 
existence — so  that  it  need  scarcely  be  reckoned.  Ex- 
ostosis of  the  root  sometimes  renders  extraction  very 
difficult,  especially  when  the  enlargement  attaches  to 
the  point  of  the  root,  and  forms  a  bulb  larger  than  the 
diameter  of  the  root  elsewhere.  It  is  then  like  a  ball 
in  a  socket,  and  if  the  walls  of  the  alveolus  are  thick 
and  firm,  and  closely  embrace  the  root,  the  tooth  is 
very  securely  retained.  Exostosis  of  the  same  extent 
in  the  inferior  as  in  the  superior  teeth  will  render  the 
former  the  more  difficult  to  remove,  because  of  the 
greater  density  of  the  inferior  maxilla ;  and  it  has  been 
maintained  that  this  cause  would  produce  a  like  dif- 
ference even  in  the  normal  condition  of  the  organs ; 
but  experience  does  not  warrant  the  opinion.  The 
superior  molars  have  more  numerous  and  more  diver- 
gent roots  than  the  inferior ;  and  the  roots  of  the  an- 
terior superior  teeth  are  much  larger,  and  consequently 
have  a  greater  amount  of  attachment,  than  the  anterior 


380  EXTRACTION    OF   TEETH. 

inferior  ones.  In  a  healthy  condition,  the  periosteum 
of  the  root  has  comparatively  little  sensibility  ;  but  in 
proportion  as  it  is  subjected  to  acute  disease,  is  the 
sensibility  increased,  and  thus  the  pain  consequent  on 
the  removal  of  the  tooth,  augmented. 

Instruments  adapted  to  all  the  different  forms  and 
locations  of  the  teeth  are  requisite  in  the  various  ope- 
rations of  extraction.  It  is  impossible  to  remove  all 
teeth  in  a  proper  manner  with  but  three  or  four  instru- 
ments, as  recommended  by  some. 

For  any  kind  of  successful  manipulation  in  the 
mouth,  and  especially  that  involved  in  the  extraction 
of  teeth,  the  patient  should  be  placed  in  such  a  posi- 
tion as  to  be  most  comfortable,  and  to  secure  to  the 
operator  the  greatest  facility  of  execution.  But  dif- 
ferent positions,  of  course,  will  be  required  for  the  re- 
moval of  different  teeth.  Finally,  there  should  be  as 
little  show  of  preparation,  and  as  little  display  of  instru- 
ments, as  possible, — thus  to  avoid  exciting  the  nervous 
apprehensions  of  the  patient ;  and  the  operator  should 
at  all  times  exhibit  a  gentle  and  encouraging  deport- 
ment, yet  work  promptly  and  surely. 


INDICATIONS    FOR    EXTRACTION. 

The  most  common  and  imperative  indication  is, 
continued  and  violent  toothache.  In  all  cases  where 
the  teeth  are  diseased  and  painful,  and  cannot  be  re- 


INDICATIONS   FOR    EXTRACTION.  381 

stored  to  health,  they  should  be  removed.  There  are, 
however,  a  few  cases  of  diseased  teeth  that  can  not  be 
relieved  by  the  present  methods  of  treatment,  so  as 
to  remain  in  the  mouth  with  any  degree  of  com- 
fort and  usefulness.  Alveolar  abscess,  terminating 
on  the  outside  of  the  face,  or  tending  to  it,  always 
indicates  the  removal  of  the  offending  tooth.  Chronic 
inflammation  of  the  investing  membrane  formerly  was 
considered  an  indication  for  extraction  ;  but  it  is 
found  that  many  cases  thus  affected  may  by  judicious 
treatment  be  restored  to  comparative  health.  Ulcera- 
tion of  the  investing  membrane  clearly  points  to  ex- 
traction as  the  remedy.  Teeth  that  have  no  antago- 
nists, and  that,  on  this  account,  keep  up  an  irritable 
condition  in  the  contiguous  parts,  that  cannot  be  con- 
trolled, should  be  removed ;  and  so,  as  a  general  rule, 
should  supernumerary  teeth.  In  order  to  relieve  a 
crowded  condition  of  the  teeth,  it  is  sometimes  neces- 
sary to  remove  one  or  more,  even  though  they  may  be 
healthy. 

Till  within  the  last  few  years,  the  existence  of  an 
alveolar  abscess  was  considered  an  indication  for  the 
removal  of  the  tooth  from  which  it  proceeded,  but 
under  the  present  mode  of  treatment,  except  in  very 
aggravated  cases,  a  simple  abscess  is  not  reckoned  a 
sufficient  cause  for  extraction. 

The  posterior  teeth  may  be  removed  for  causes  that 
would  not  warrant  the  removal  of  the  anterior.     All 


382  EXTR  VCTI03    OF    TEETH. 

dead  teeth  and  roots  thai  produce  or  keep  up  irritation 
should  be  removed,  especially  if  the  tendency  is  per- 
sistent. 

The  temporary  teeth  thai  are  nol  cast  at  or  near  the 
time  their  respective  permanenl  teeth  should  appear 
through  the  gum,  ought  to  be  removed;  bul  caution 
inu-t  always  be  exercised,  lest  they  be  removed  too 
soon.  Painful  and  uncontrollable  disease  may  indi- 
cate their  removal  long  before  the  period  just  men- 
tioned :  vet  they  should  not  be  removed  on  account 
of  diseased  condition  unless  the  rudiments  of  the  per- 
manent teeth  are  likely  to  suffer  by  such  disease.  A 
crowded  condition  of  the  permanent  with  the  tempo- 
rary teeth  mav  indicate  the  removal  of  one  or  more 
of  the  latter.  It  is  important  to  understand  the  true 
indications  for  the  removal  of  temporary  teeth  ;  in 
these,  as  in  the  permanenl  teeth,  apparent  indications 
are  liable  to  be  mistaken  for  real  ones.  Teeth  may 
sometimes,  even  though  undecayed,  produce  nervous 
affections,  and  in  such  a  manner  as  to  render  their  re- 
moval necessary.  This  indication  is  most  frequent 
with  teeth  affected  by  exostosis. 

A  high  state  of  inflammation  in  the  contiguous 
parts  is  regarded  by  some  as  a  counter-indication; 
but  it  can  be  such  only  in  cases  in  which  the  inflam- 
mation would  be  increased  by  the  operation;  and  this 
would  happen  only  where  there  is  a  decided  inflamma- 


EXTRACTING   INSTRUMENTS.  383 

tory  diathesis,  which  peculiarity  can   be  readily  de- 
tected by  careful  observation. 


Extracting  Instruments 

Numerous  and  various  instruments  have  been  em- 
ployed for  extracting  teeth  ;  and  each  of  these  has 
passed  through  various  modifications.  Imperfection 
and  want  of  adaptation  have,  till  within  a  few  years, 
characterized  them  all  in  a  marked  degree,  as  indi- 
cated by  numerous  changes  they  have  undergone. 
Two  general  classes  comprehend  them  all,  represented 
by  the  key  and  the  forceps.  The  former  makes  its 
attachment  on  one  side  of  the  tooth,  coming  in  con- 
tact with  but  a  small  portion  of  it,  and  has  a  resting- 
point  for  a  fulcrum  on  the  adjacent  parts,  the  gum 
and  the  alveolus.  The  latter  embraces  the  tooth  on 
both  sides,  and  has  no  fulcrum  resting  on  the  adjacent 
parts.  There  are  other  instruments  somewhat  different 
from  these  in  their  application  ;  but  the  principle  on 
which  they  operate  is  the  same.  For  instance,  the 
elevator  has  a  point  of  embrace  or  contact  with  the 
teeth,  and  a  fulcrum  or  resting-point  on  the  adjacent 
parts,  the  power  being  applied  to  the  handle,  as  to  a 
lever.  The  screw  makes  its  attachment  inside  of  the 
tooth,  instead  of  outside,  like  the  forceps,  and  does 
not  touch  any  other  part. 

There  should  always  be  at   hand  a  sufficient  nuna- 


384  EXTRACTION   OF   TEETH. 

ber  and  variety  of  instruments  to  meet  every  case, 
however  rare  its  occurrence.  Desirabode  recommends 
the  employment  of  but  four  instruments  for  the  re- 
moval of  all  the  teeth.  The  first  is  a  forceps,  and  the 
other  three  are  nothing  more  than  so  many  different 
forms  of  the  elevator.  He  was  not  familiar  with  the 
present  improvements  in  extracting  instruments,  or  he 
could  not  have  made  such  a  recommendation. 


The  Key. 

The  principle  of  this  instrument  was  at  a  very 
early  period  brought  into  requisition  for  the  extrac- 
tion of  teeth ;  it  is  emphatically  an  old  instrument. 
It  consists  of  a  shaft  six  inches  long,  with  a  handle 
four  inches,  attached  at  right  angles,  while  the  hook 
is  attached  laterally  at  the  other  end  of  the  shaft,  and 
the  bolster,  either  movable  or  fixed,  to  the  side  of  it, 
immediately  below  the  articulation  of  the  hook.  This 
instrument  has  passed  through  a  great  variety  of  forms 
and  modifications  ;  having  the  shaft  straight,  curved, 
or  double  curved ;  the  fulcrum  large,  small,  flat,  round, 
long,  short,  fixed,  movable,  and  anterior,  posterior,  or 
opposite  to  the  point  of  the  hook.  There  has  also 
been  a  great  variety  of  forms  of  the  hook ;  and  it 
has  been  made  with  machinery  attached,  to  control  its 
grasp,  the  object  of  which  is  to  prevent  the  instrument 
from  slipping  off  the  tooth,  and  skill  in  the  use  of 


THE   KEY.  385 

which  would  doubtless  add  to  the  efficiency  of  the  in- 
strument. The  principle  of  the  forceps,  too,  has  been 
combined  with  the  key,  and  probably  with  very  de- 
cided advantage. 

The  modus  operandi  of  the  key  is  worthy  of  some 
consideration.  The  hook  is  attached  to  the  shaft  di- 
rectly above  the  bolster,  and  starts  off  at  a  right  angle 
with  its  vertical  axis,  but  curves  down  to  the  point, 
almost  or  quite  as  low  as  the  base  of  the  bolster. 
When  properly  constructed,  the  hook  embraces  the 
tooth  at  the  neck  on  one  side,  and  the  bolster  rests  a 
little  below  this  on  the  other.  When  the  instru- 
ment is  applied  to  a  tooth,  the  centre  of  the  shaft  is 
the  axis  of  motion  ;  but  as  force  is  applied  to  the  in- 
strument, this  axis  is  transferred  from  the  shaft  to  the 
base  of  the  bolster,  which  is  the  centre  of  motion  the 
moment  it  is  fixed  on  the  gums  and  alveolus,  and  the 
shaft  describes  an  arc  about  it.  Now,  as  a  result  of 
this  motion  and  arrangement,  the  line  of  force  is  at 
an  angle  of  from  forty  to  sixty  degrees  with  the  axis 
of  the  tooth ;  and  hence  it  is  at  this  angle  that  the 
tooth  must  be  extracted,  if  at  all.  The  axis  of  power 
exerted  on  the  tooth  by  the  instrument  is  in  a  line 
from  the  point  of  the  hook  to  its  attachment  to  the 
shaft ;  and  the  line  of  this  force  has  its  termination 
below  the  neck  of  the  tooth  on  one  side,  and  just 
above  the  crown  on  the  opposite  side.  The  angle 
formed  by  the  line  of  power  with  the  axis  of  the 

25 


386  EXTRACTION    OF   TEETH. 

tooth  is  different  in  the  different  relative  positions  of 
the  key  to  the  tooth.  If  the  instrument  is  applied  to 
an  inferior  molar,  with  the  bolster  on  the  inside,  the 
angle  of  the  line  of  force  with  the  axis  of  the  tooth  is 
about  forty  degrees ;  but  if  placed  on  the  outside  of 
the  jaw,  as  recommended  by  some,  the  angle  con- 
tained by  the  line  of  power  and  the  axis  of  the  tooth 
is  sixty  degrees  or  more.  The  line  of  force  is  not 
changed  by  any  form  the  hook  may  assume  ; — it  may 
be  regularly  or  irregularly  curved,  or  be  turned  at 
a  right  angle,  and  yet  the  line  of  force  is  not  changed. 
Indeed,  this  line  cannot  be  changed  except  by  chang- 
ing the  relative  position  of  the  hook  and  its  attach- 
ment. This  application  of  the  power  constitutes  one 
of  the  prominent  objections  to  the  use  of  the  instru- 
ment ;  the  force  is  applied  at  too  great  an  angle  with 
the  axis  of  the  tooth,  and  hence  in  numerous  instances 
it  is  broken  off.  The  bolster  of  the  key  rests,  in 
the  operation,  on  the  gum,  on  which  it  exerts  great 
pressure,  and  which  it  always  bruises,  and  frequently 
lacerates  in  a  cruel  manner  ;  the  pressure  exerted  by 
the  bolsters  of  the  variously  constructed  keys  differs 
but  little ;  though,  perhaps,  the  bolster  which  has  a 
broad  base,  and  is  attached  to  the  -shaft  by  a  joint, 
would  cause  less  pain  to  the  patient  by  its  pressure, 
and  be  much  less  liable  to  lacerate  or  cut  the  gum, 
than  the  small  and  permanent  one.  The  pressure  of 
the  bolster  on  the  gum   and  process  is  always  greater 


THE    KEY. 


387 


than  the  power  required  to  extract  a  tooth ;  and  this 
extreme  pressure  and  its  consequences  constitute  an- 
other strong  objection  to  the  use  of  the  key.  The 
power  being  applied  at  a  disadvantage,  much  more 
is  required  than  when  economically  applied. 

This  instrument  is  so  seldom  employed  for  the  ex- 
traction of  teeth,  that  any  very  special  directions  as 
to  its  use  will  scarcely  be  required  ;  yet  a  few  general 
suggestions  may  not  be  out  of  place.      Whether  a 
tooth  should  be  drawn  inward  or  outward  depends 
on  its  position  and  inclination.     As  a  general  rule  for 
the   removal   of  the   molars,  the   bolster  should  be 
placed  on  the  inside  of  the  inferior  teeth  and  on  the 
outside  of  the  superior.      For   removing   the   lower 
teeth  of  the  left  side,  the  operator  should  stand  at  the 
right  of  the  patient ;  and  for  the  teeth  of  the  right 
side,  in  front  or  at  the  right.     For  the  inferior  teeth 
of  the  right  side,  he  should  stand  at  the  right  of  the 
patient ;  and  for  the  left  superior,  in  front  of  him. 
There  have  been  a  great  many  different  opinions  as 
to  the  manner  of  applying  and  using  this  instrument. 
One  recommends  that  "the  teeth   should  be  always 
turned  towards  the   tongue."      Another,    "that   the 
fulcrum  should  be  so  placed  that  it  would  not  come 
in  contact  with  the  tooth."     Another  directs  :  "  Place 
the  fulcrum  on  the  margin  of  the  gum."     Another: 
"  Place  the  fulcrum  on  the  gum  below  its  margin." 
Another  suggests,  "that  the  fulcrum  be  placed  on  the 


388  EXTRACTION    OF     I  EE1  II. 

side  of  the  tooth  opposite  the  poinl  of  the  hook." 
Again:  "We  are  directed  thai  the  tooth  should  be 
drawn  from  the  higher  alveolus."  This  greal  diversity 
of  opinion  as  to  the  manner  of  using  the  key,  as  well 
as  the  great  variety  of  changes  in  its  form,is  evidence 
that  it  is.  at  best,  a  very  imperfect  instrument.  It  is 
impossible  to  embrace  a  tooth  as  deep  with  it  as  with 
well-constructed  forceps;  and  with  it,  the  liability  to 
accident  in  the  extraction  of  teeth  is  much  greater 
than  with  any  other  instrument.  A  strong  advocate 
of  this  instrument  says  that  the  key  always  produces 
injury;  but  the  greatest  skill  exhibits  the  least  injury. 

Forceps. 

The  forceps  are  the  most  efficient  extracting  instru- 
ments in  use,  and  the  improvements  made  in  them 
during  the  last  few  years  have,  been  very  great ;  in- 
deed, twenty-live  years  ago  they  were  not  made  with 
any  special  adaptation  whatever,  and  were  totally  un- 
fit to  be  used  for  the  extraction  of  teeth  ;  but  now 
they  are  constructed  with  such  various  shapes  and 
curves  as  to  facilitate  their  approach  to  the  teeth 
whatever  their  position  in  the  mouth  may  be,  and  to 
fit  all  the  various  forms,  and  make  a  most  perfect  em- 
brace of  the  teeth.  Forceps,  with  the  present  im- 
provements, take  a  deeper  and  more  thorough  hold  on 
the  teeth  than  any  other  instrument.     The  beaks  may 


FORCEPS.  389 

be  made  so  thin  that  they  will  penetrate  between  the 
roots  and  alveolus,  and  the  adaptation  so  complete  that 
the  instrument  will  not  slip  or  move  from  its  position 
when  placed.  The  form  of  the  beaks  should  be  such 
as  to  fit  the  crown  without  pressing  on  it,  and  yet  per- 
fectly embrace  the  neck  of  the  tooth ;  and  the  entire 
instrument  of  such  form  and  curve  as  to  give  to  the 
hand,  arm,  and  body  of  the  operator  the  best  position 
for  ease  and  facility  of  execution. 

There  are  various  opinions  as  to  the  position,  rela- 
tive to  the  patient,  which  the  operator  should  occupy 
while  extracting  teeth  with  the  forceps.  Some  recom- 
mend different  positions  for  the  removal  of  different 
teeth;   but  it  is  preferable,  on  many  accounts,  to  oc- 

Fio.  100. 


cupy  as  nearly  as  possible  the  same  position  in  the  re- 
moval of  all ;  and  this  is  to  the  right  and  a  little  back 
of  the  patient. 

The  forceps  for  removing  the  superior  incisors  are 
straight  and  have  thin  beaks,  which  are  sufficiently 
broad  to  embrace  the  anterior  and  the  posterior  sur- 
facee  of  the  teeth  entire  (Fig.  100)  ;  and  they  should 
be  much  broader  for  the  centrals  than  for  the  laterals. 


390  EXTRACTION    OF   TEETH. 

The  points  should  not  be  so  broad,  however,  as  to  come 
in  contact  with  the  contiguous  teeth  in  the  rotary 
motion  made  to  break  up  the  attachment.  The  same 
principle  in  regard  to  the  width  of  the  forceps  is  to 
be  observed  for  the  lateral  incisors  and  cuspids.  The 
ordinary  straight  root  forceps  may  be  employed  for 
the  extraction  of  the  lateral  incisors ;  though,  for  this 
purpose,  it  is  desirable  that  their  beaks  be  somewhat 
thinner  than  usual.  For  the  superior  cuspid  teeth, 
the  ordinary  bicuspid  forceps  are  frequently  used,  but 
their  beaks  are  commonly  too  narrow,  and  those  of  the 

Fig..  101. 


'  1 

central  incisor  forceps  too  thin.  The  cuspid  forceps 
should  be  about  as  wide  as  those  for  the  central  in- 
cisors, with  the  thickness  of  the  bicuspid  forceps  (Fig. 
101),  and  with  a  greater  concavity,  so  as  to  fit  the 
neck  of  the  tooth.  The  superior  bicuspid  forceps 
have  narrow,  thick,  and  quite  concave  beaks,  and  the 
instrument  is  straight,  or  nearly  so,  though,  for  the 
second  bicuspids,  especially  in  a  small  mouth,  it  should 
have  some  anterior  curvature.  (Fig.  102.)  One  pair 
of  forceps  will  serve  for  both  sides,  though  it  is  de- 
sirable to  have  one  for  the  first  and  another  for  the 


FORCEPS. 


391 


second  bicuspid.  For  the  removal  of  the  bicuspids  there 
is  a  form  of  forceps  with  thick,  smooth  beaks,  and  of 
such  a  form  as,  by  pressure,  to  force  the  tooth  from 
its  socket,  taking  advantage  for  this  purpose  of  the 

Fig.  102. 


conical  form  of  the  root.  The  superior  molar  forceps, 
a  pair  for  each  side,  have  one  of  the  beaks  a  single 
concave,  to  embrace  the  palatine  root,  and  the  other  a 
double  concave,   with    a    projecting    point   from  the 

Fig..  103. 


centre  of  the  beak,  to  pass  into  the  bifurcation,  and 
with  the  edge  of  the  beak  so  formed  as  to  embrace 
the  two  palatine  roots.     The  concavity  and  curvature 


392 


EXTRACTION    OF   TEETH. 


of  the  beaks  should  be  just  sufficient  to  accommodate 
the  crown  of  the  tooth.  These  forceps  should  have  a 
double  curve  to  facilitate  their  approach  to  the  teeth, 
an  anterior  curve  just  above  the  joint,  and  a  down- 
ward curve  just  below  it ;  sometimes,  also,  a  lateral 
curve  above  the  joint,  throwing  the  instrument  more 
toward  the  angle  of  the  mouth.     (Fig.  103.) 

For  the  second  molars,  the  forceps  should  have  a 
little  more  curve  above  the  joint  than  for  the  first. 


Fig.  104. 


A  third  pair  of  forceps  for  these  teeth,  and  especially 
for  the  roots  before  they  are  separated,  have  the  inner 
beak  similar  to  the  one  above,  and  the  outer  a  curved, 
attenuated,  sharp  point,  to  pass  between  the  buccal 
roots  (Fig.  104).     The  forceps  for  the  superior  third 


FORCEPS. 


393 


molars  have  two  single-concave  beaks,  made  to  em- 
brace the  tooth  as  though  it  were  cylindrical,  or  nearly 
so,  at  its  neck.  The  instrument  has  two  curves,  or 
rather  angles,  the  one  forward  and  the  other  down- 
ward, so  that  its  handle  is  somewhat  anterior  to,  but 

Fig.  105. 


almost  parallel  with  the  axis  of  the  tooth.  (Fig.  105.) 
It  is  a  principle  that  should  be  observed  in  all  forceps, 
that  the  handle  of  the  instrument  when  placed  upon 
the  tooth  be  as  nearly  parallel  with  the  axis  of  the 


Fig.  106. 


latter  as  possible,  and  as  nearly  in  a  line  with  it  as  the 
location  of  the  tooth,  the  size  of  the  mouth,  and  other 
circumstances  will  admit. 

The  forceps  for  the  inferior  incisors  may  have  either 


;;!•! 


EXTRACTION    OF    TEETH. 


a  lateral  or  a  transverse  curve, — almost  to  a  right  an- 
gle if  transverse,  but  if  lateral,  not  more  than  half  that 
inclination.  (Fig.  106.)  The  ordinary,  slightly  curved 
root  forceps  may  be  used  for  the  extraction  <>f  these 
teeth.   (Fig.  107.)     The  beaks  should  be  very  narrow 

Fig.  107. 


and  thin,  for  a  great  amount  of  force  is  not  required 
for  the  extraction  of  these  teeth.     The  beaks  of  the 

inferior  incisor  forceps  should  be  relatively    broader 

Fig.  108. 


than  those  of  the  forceps  for  the  superior  incisors. 
Rotary  motion  in  the  extraction  of  inferior  incisors  is 
not  admissible  unless  the  roots  be  cylindrical,  or  nearly 
so.     The  inferior  bicuspid  forceps  are  well  adapted  to 


FORCEPS. 


395 


the  removal  of  the  inferior  cuspids  also.  These  forceps, 
two  in  number,  one  for  each  side,  are  of  different  forms. 
(Fig.  108.)  The  beaks  are  narrow,  thick,  and  quite 
concave.  The  instrument  for  the  right  side  has  a  lat- 
eral curvature,  which  brings  the  handle  out  at  the 
angle  of  the  mouth,  and  is  necessary  in  order  to  obviate 
a  contact  with  the  superior  teeth.  The  forceps  for  the 
left  side  have  beaks  of  the  same  form.     They  are  bent 

Fig.  109. 


to  almost  a  right  angle  above  the  joint,  while  below  it 
the  handle  is  thrown  upward  ;  and  their  inner  beak  is 
longer  than  the  outer.  The  inferior  molar  forceps 
(Fig.  109)  are  two  in  number,  that  for  the  right  side 
being  curved  outward  and  forward,  and  that  for  the 
left  forward  and  upward,  the  beak  making  almost  a 
right  angle  with  the  body  of  the  instrument,  and  the 


396  EXTRACTION    OP    TEETH. 

inner  beak  of  eaeh  being  longer  than  the  outer.  The 
beak  should  be  of  sufficient  breadth  to  embrace  the 
entire  side  of  the  tooth,  of  double-concave  form,  with 
a  ridge  and  a  long  point  in  the  centre  of  the  beak,  to 
pass  into  the  bifurcation  of  the  roots.  The  inner  beak 
of  these  forceps  should  be  longer  than  the  outer,  for 
the  teeth  on  which  they  are  designed  to  operate  have 
an  inward  inclination,  and  the  outer  alveolus  is  higher 
than  the  inner. 

A  pair  of  forceps  for  the  left  side,  similar  in  form  to 
those  for  the  right,  would  be  preferable  to  the  ordinary 
left  forceps,  when  the  mouth  can  be  opened  wide ;  and 
the  curvature  of  the  handle  of  this  instrument  would 
be  toward  the  centre  of  the  mouth,  instead  of  outward, 
as  that  of  the  right  forceps.  With  this  form  of  forceps 
more  power  can  be  exerted  than  with  the  ordinary  left 
inferior  forceps. 

A  forceps  similar  in  general  form  to  that  for  the  ex- 
traction of  the  inferior  molars  of  the  right  side  has  been 
devised  by  Dr.  J.  A.  Watling,  for  the  removal  of  the 
lower  molars  of  the  left  side. 

The  instrument  has  a  little  more  upward  and  for- 
ward curve  above  the  joint  than  for  the  right  side,  to 
facilitate  its  approach  to  and  action  upon  the  tooth  for 
which  it  is  designed ;  it  is  a  little  longer  than  that  for 
the  right  side.  This  instrument  is  much  more  easily 
controlled  than  the  ordinary  forceps  used  for  extract- 
ing these  teeth,  and  with  it  more  force  can  be  applied. 


FORCEPS. 


397 


It  is  far  preferable  to  any  forceps  hitherto  used  for  the 
extraction  of  the  left  inferior  molars.  It  is  represented 
by  Fig.  110. 


Fig.  110. 


Forceps  for  the  removal  of  the  inferior  third-molars 
have  large  single-concave  beaks,  to  make  a  general 
embrace  of  the  tooth,  and  have  but  one  curve,  which 
is  between  the  joint  and  the  point,  and  is  almost  a 
right  angle.   (Fig.  111.)     One  pair  of  forceps  of  this 

Fig.  111. 


kind  is  quite  sufficient  for  both  the  right  and  the  left 
Bide.  The  forceps  denominated  Physic's  forceps  are 
also  sometimes  employed  for  the  removal  of  the  third- 
molars.  These  are  constructed  with  thick,  sharp 
blades,  the  edges  of  which  come  squarely  together,  and 
the  points  sometimes  have  an  enlargement  on  them. 
They  are  curved  almost  to  a  right  angle,  to  facilitate 
their  adaptation.  (Fig.  112.)  There  are  two  or  three 
different  forms  of  Physic's  forceps. 


398  EXTRACTION   OF  TEETH. 

Of  the  variety  of  root  forceps  now  used,  those  for 
the  removal  of  the  anterior  teeth  are  straight,  or  but 
slightly  curved,  with  long,  thin,  sharp-edged  beaks, 
and  of  a  width  regulated  by  the  diameter  of  the  roots. 
Those  for  the  removal  of  the  roots  of  the  superior 
molars,  when  these  are  separated,  have  the  same  form 
of  beaks  as  those  for  the  front  teeth,  but  more  curved, 
to  facilitate  their  approach  to  the  roots.     For  the  re- 

Fig.  112. 


moval  of  these  roots,  it  is  well  to  have  several  pairs 
of  forceps  with  different  degrees  of  curvature,  using, 
in  any  given  case,  those  with  the  least  admissible 
curve, — which  in  a  small  mouth  will  be  considerable, 
while  in  a  large  one  it  will  be  very  slight.  The  same 
forceps  that  are  used  for  the  removal  of  the  front 
inferior  teeth  are  applicable  to  the  removal  of  their 
roots. 

Of  the  different  forms  of  forceps  for  the  removal  of 
the  roots  of  inferior  molars,  those  for  the  extraction 
of  the  roots  before  they  are  separated,  and  while  they 
are  firmly  attached,  have  two  long,  slender,  round, 
curved  beaks,  designed  to  pass  down  deep  between 
and  embrace  the  roots  in  the  bifurcation  ;  their  curva- 
ture should  be  almost  a  right  angle,  and  their  handles 


FORCEPS. 


399 


assume  the  form  of  the  ordinary  right  and  left  inferior 
molar  forceps,  already  described  (Fig  113)  ;  or  if  but 
one  is  used,  the  handle  should  be  straight.     The  for- 

Fig.  113. 


ceps  for  the  removal  of  these  roots  after  they  are  sep- 
arated should  have  the  beaks  of  the  same  form  as 


Fig.  114. 


those  of  the  superior  root   forceps;    but   the   beaks 
should   be  curved  to  a  right  angle  with  the  handle, 

Fig.  114.) 


and  the  handle  be  straight 


400 


EXTRACTION    OF    TEETH. 


Elevators. 

There  are  in  use  variously-formed  instruments  con- 
structed on  the  principle  of  the  elevator.  They  are 
made  with  such  points  as  to  lake  the  mosl  thorough 
hold  on  the  teeth  or  roots  on  which  they  arc  to  be 
used,  and  with  such  curvature  of  shaft  as  to  enable 
thern   to  pass  most  readily  to  the   desired    position. 

Fig.  L15. 


Some  are  so  formed  at  the  points  as  to  embrace  the 
root  at  the  border  of  the  alveolus,  using  the  latter  as 


Fig.  116. 


a  fulcrum  (Fig.  115)  ;  others,  to  pass  between  the  al- 
veolus and  the  root  (Fig.  116)  ;  others  to  cut  through 
the  alveolus,  and  thus  approach  the  root.  All  the  or- 
dinary elevators  make  a  fulcrum  of  the  alveolus,  or  of 
an  adjoining  tooth;  but  some  operators,  in  using  this 
instrument,  contrive  to  make  a  fulcrum  of  the  thumb 
or  one  of  the  fingers,  which  is  the  preferable  way. 


HOOKS — SCREW. 


401 


Hooks. 

These  are  formed  so  that  the  point  will  embrace 
the  root  and  remove  it,  without  resting  on  the  sur- 
rounding parts.     The  root  is  removed  simply  by  pres- 

Fig.  117. 


sure,  applied  in  the  proper  direction.  Of  the  various 
forms  of  this  instrument,  there  are  the  forward  hook, 
the  backward   (Fig.   117),  and  the  compound    (Fig. 


Fig.  118. 


118),  which  last  includes  the  former  two.  These  are 
valuable  instruments,  but  require  care,  in  order  to 
avoid  injuring  the  surrounding  parts. 


Screw. 

This  is  a  cone-shaped  instrument,  with  a  very  defi- 
nite, sharp  screw-thread ;  the  manner  of  using  it  in 
tlif  operation  of  extraction  is,  to  screw  it  into  the  root. 
It  will  \)c  required  of  various  sizes,  to  correspond  with 

26 


402  EXTRACTION    OF   TEETH. 

those  of  tlic  different  roots  to  be  extracted.  It  is 
commonly  attached  to  the  handle  by  a  permanent 
shaft   (Fig.    119) ;  but  sometimes  it  is  made  with  a 

Fig.  119. 


square  shaft  fitted  into  a  socket  handle  (Fig.  120), 
by  which  arrangement  the  handle  is  used  only  to  in- 
troduce the  screw ;  and  this  only  serves  as  a  support 
to  a  frail  root,  the  forceps  being  then  brought  to  bear 


Fig.  120. 


in  connection  with  it  for  the  removal  of  the  root.  A 
screw-tap  of  the  same  form  as  the  screw  should  accom- 
pany it. 

When  the  screw  is  combined  with  the  forceps  for 
the  purpose  of  supporting  the  root,  and  preventing  it 
from  crushing  while  it  is  removed  with  the  forceps, 
the  latter  is  of  the  same  form  as  that  of  the  ordinary 
straight  root  forceps,  with  the  shaft  of  the  screw  at- 
tached in  the  joint.  In  some,  the  screw  is  attached 
with  a  spring  and  ratchet,  so  that  it  can  be  drawn  out, 
seized  between  the  beaks,  and  introduced  into  the  root; 
and  then,  these  are  slipped  on  the  root,  which  they 


GUM-LANCET.  403 

embrace  and  remove.  In  others,  the  screw  is  fixed, 
but  the  movable  screw  is  to  be  preferred.  (Fig.  121.) 
An  arm  attached  by  a  joint,  and  bearing  a  pad  to  rest 

Fig.  121. 


as  a  fulcrum  on  the  other  teeth,  is  sometimes  attached 
to  the  shaft  of  the  screw,  but  this  is  objectionable,  be- 
cause of  its  liability  to  impede  the  action  of  the  in- 
strument, and  also  to  injure  the  adjoining  teeth. 

G  CM-LANCET. 

Of  the  various  forms  of  the  gum-lancet,  the  most 
common  is  that  with  the  round  point,  and  with  the 
blade  from  two  to  four  lines  wide,  and  from  half  an 
inch  to  an  inch  long,  attached  to  a  shaft  and  handle, 
the  whole  being  about  six  inches  in  length.     The  in- 

Fig.  122 


strument  should  have  a  keen  edge  on  the  sides,  two  or 
three  lines  from  the  extreme  point.  It  is  sometimes 
made  with  the  edge  square,  but  the  round  edge  is  the 
better  form.  The  edge  is  parallel  with  the  handle  in 
the  ordinary  lancet.   (Fig.  122.)     This  form  is  used 


404  EXTRACTION   OF  TEETH. 

for  separating  the  gum  from  the  buccal  and  palatal 
surfaces  of  the  tooth.  A  lancet  with  the  edge  trans- 
verse to  the  shaft  is  required  for  separating  the  gum 
from  the  proximate  portions  of  the  teeth.  The  blade 
of  this  should  be  of  the  same  general  form  as  that 
already  described,  except  that  it  should  be  quite  nar- 
row, in  no  case  more  than  two  lines  wide.    (Fig.  123.) 

Fig.  123. 


Gum-lancets  are  made  with  the  blade  set  in  a  socket 
on  the  end  of  the  shaft,  so  that  it  can  be  rotated  and 
set  to  any  angle  to  meet  every  case. 


The  Method  of  Lancing  the  Gums. 

In  all  cases  the  gum  should  be  separated  from  the 
tooth  as  far  as  the  embrace  of  the  forcejDS  is  to  extend ; 
the  lancet  should  pass  close  to  the  tooth,  so  as  to  make 
the  separation  clean  about  its  neck;  in  order  to  do 
which  the  lancet  must  be  kejit  in  good  condition ;  it 
should  also  be  passed  freely  between  the  teeth.  A 
complete  separation  of  the  gum  is  essential  to  a  good 
hold  of  the  forceps  on  the  tooth.  Some  operators, 
however,  do  not  use  the  lancet  for  this  purpose,  but 
tear  the  gum  away  by  forcing  the  forceps  to  its  posi- 


METHOD   OF   LANCING   THE   GUMS.  405 

tion  on  the  tooth.  This  method  is  objectionable  on 
several  accounts:  it  causes  the  patient  much  more  pain 
than  with  a  sharp  lancet;  the  forceps  cannot  thus  be 
adjusted  to  the  tooth  with  so  much  facility;  there  is 
far  more  danger  of  lacerating  the  soft  parts,  and  be- 
cause of  an  imperfect  adaptation  of  the  forceps  to  the 
tooth,  more  danger  of  fracturing  it ;  and  the  opera- 
tion is  always  more  difficult  of  accomplishment.  In 
those  cases  in  which  the  gum  is  firm  and  dense,  and 
would  obstruct  the  free  passage  of  the  forceps  to  the 
proper  position  on  the  tooth,  it  is  sometimes  necessary 
to  make  a  vertical  incision  of  the  gum,  even  after  it 
has  been  separated,  directly  opposite  the  root.  But  it 
is  in  many  instances  better  to  cut  away  a  portion  of 
the  free  margin  of  the  gum  in  the  extraction  of  roots 
that  are  partially  covered  by  it;  and  there  is  no  objec- 
tion to  this  method  in  any  case  where  it  may  at  all  fa- 
cilitate the  operation;  for  this  portion  of  the  gum,  if 
let  remain,  is  always  absorbed  or  sloughed  away  after 
the  extraction  of  teeth.  It  is  also  sometimes  necessary 
to  dissect  the  gum  somewhat  from  the  alveolus,  in 
those  cases  in  which  a  deep  hold  on  the  tooth  or  root 
is  required,  and  in  which  the  alveolus  is  either  cut 
away  or  embraced  by  the  forceps.  The  character  and 
condition  of  the  tooth  will  somewhat  modify  the  ex- 
tent to  which  the  gum-lancet  should  be  used. 


406  EXTRACTION   OF   TEETH, 

Extraction  of  the  Teeth. 

In  the  following  remarks  it  is  the  design  to  consider 
only  those  principles  obviously  involved  in  the  ex- 
traction of  the  teeth  with  forceps,  and  in  the  extraction 
of  roots  with  forceps,  elevators,  and  screws. 

Superior  Incisors. — After  an  examination,  the  gum 
should,  in  all  cases,  be  perfectly  separated  from  the 
neck  of  the  tooth  up  to  the  border  of  the  alveolus; 
this  is  quite  sufficient  if  the  tooth  is  not  too  much  de- 
cayed. With  the  forceps  already  described  (see  Fig. 
100),  grasp  the  tooth  firmly  at  the  border  of  the  al- 
veolus; introduce  the  instrument  slowly,  adjusting  it 
carefully  as  it  passes  up  to  the  proper  position;  then, 
by  a  gradual  movement,  rotate  the  tooth  in  the  socket, 
thus  breaking  up  the  attachment.  All  the  cylindrical, 
single-root  teeth  may  be  luxated  by  a  rotary  motion. 
There  are  occasional  circumstances,  however,  that  ren- 
der this  somewhat  difficult ;  as,  for  instance,  any  con- 
siderable curvature  of  the  root,  or,  sometimes,  the  at- 
tachment to  the  outer  plate  of  the  alveolus  is  so  firm 
that  it  cannot  be  broken  up  by  rotary  motion.  Neither 
of  these  difficulties  is  usual  with  the  lateral  incisors; 
but  writh  the  centrals,  one  or  other  of  them,  is  not  un- 
frequent.  When  either  of  them  does  occur,  the  at- 
tachment must  be  broken  up  by  an  inward  and  out- 
ward movement,  which,  on  account  of  the  pressure 
made  on  the  parts,,  is  attended  with  mnch  more  pain, 


EXTRACTION   OF   TEETH.  407 

and  far  greater  danger  to  the  contiguous  parts  than  the 
loosening  by  rotary  motion. 

The  roots  of  the  incisors  are  not  difficult  to  remove, 
unless,  being  very  much  decayed,  they  will  not  sustain 
the  embrace  of  the  forceps  below  the  border  of  the 
alveolus;  and  when  they  are  thus  decayed,  one  of  the 
following  methods  may  be  adopted:  The  gum  may  be 
dissected  from  the  alveolus,  and  the  latter  cut  away 
with  the  thick  cutting  instrument,  so  as  to  expose  the 
root  sufficiently  for  extraction  with  the  root  forceps; 
or,  after  the  gum  is  dissected  up,  the  alveolus  and  the 
root  may  be  together  embraced,  and  the  former  bro- 
ken and  removed  with  the  latter.  This  is  a  rough 
and  severe  operation,  though  it  is  often  adopted.  Or, 
an  elevator  of  the  proper  form  may  be  introduced 
between  the  root  and  the  alveolus,  and  the  root  thus 
dislodged. 

The  screw,  either  simple  or  compound,  is  a  valuable 
instrument  for  the  removal  of  these  roots.  But  the 
gum  should  be  separated  even  when  the  extraction 
is  to  be  accomplished  with  this.  The  canal  in  the 
root  should  first  be  enlarged  with  a  taper  drill  of  the 
same  shape  as  the  screw,  till  all  the  softened  dentine 
is  removed.  Then  the  screw,  selected  of  proper  size, 
having  a  very  sharp  thread,  is  introduced,  till  it  takes 
a  strong  hold  in  the  solid  dentine,  especially  if  it  is 
the  hiii pi'-  screw.  In  some  instances,  while  it  is  being 
introduced,  the  root  will  be  loosened.     In  using  the 


408  EXTRACTION    OF   TEETH. 

screw  in  connection  with  the  forceps,  it  is  not  necessary 
to  introduce  it  with  the  same  firmness  as  when'  the 
screw  alone  is  employed.  In  the  use  of  the  screw- 
forceps,  the  screw  is  embraced  in  the  beaks  and  intro- 
duced; then  the  forceps  are  passed  up  on  the  root,  or 
between  it  and  the  alveolus,  if  need  be,  the  screw  serv- 
ing to  sustain  the  root  under  the  pressure  of  the  for- 
ceps. The  attachment  of  the  root  is  broken  by  a 
rotary,  or  an  inward  and  outward  movement,  as  the 
case  may  require. 

Superior  Cuspids. — For  the  removal  of  these  teeth, 
the  central  incisor  or  the  bicuspid  forceps  may  be 
used,  though  usually  the  beaks  of  the  former  are  too 
thin,  and  those  of  the  latter  too  narrow.  The  forceps 
appropriate  for  the  removal  of  these  teeth  have  broad, 
deep,  concave  beaks,  so  as  to  embrace  the  tooth  as 
completely  as  possible,  and  they  are  thick,  so  as  to 
possess  sufficient  strength.  The  gum  being  separated, 
and  the  forceps  adjusted  on  the  tooth,  the  attachment 
is  broken  up  either  by  an  inward  and  outward,  or  by 
a  rotary  movement ;  the  former  will  be  far  more  fre- 
quently brought  into  requisition,  since  these  teeth 
are  generally  so  firmly  attached  that  they  cannot  be 
loosened  by  the  latter;  but  the  skilful  and  experienced 
operator  will  often  combine  the  two,  with  the  happiest 
effect.  These  teeth  have  larger  roots  than  any  others 
in  the  mouth,  and  the  alveolar  process,  especially  the 
outer  plate,,  closely  invests  them,  and  thus  they  are 


EXTRACTION   OF    TEETH.  409 

very  firmly  fixed  in  the  sockets,  and  are  also  more  fre- 
quently found  curved  than  the  roots  of  the  incisors. 
Often,  in  the  extraction  of  the  cuspids,  a  portion  ot 
the  outer  wall  of  the  alveolus  is  broken  off,  and  comes 
away  with  the  tooth.  But  this  accident  is  not  attended 
with  any  serious  results;  indeed,  in  the  preparation  of 
the  mouth  for  artificial  teeth,  it  is  desirable  that  it  be 
broken  away  somewhat. 

The  movement  in  the  extraction  of  a  tooth  should 
always  be  very  deliberate — never  sudden  and  violent. 
A  very  good  criterion  in  regard  to  the  rapidity  of 
movement  is,  that  the  eye  should  follow  and  distinctly 
recognize  every  motion  of  the  forceps,  the  tooth,  and 
the  contiguous  parts. 

The  removal  of  the  roots  of  these  teeth  is  far  more 
difficult  than  that  of  the  incisors.  Frequently  the  gum 
has  to  be  separated  up  two  or  three  lines  on  the  alve- 
olus, and  the  latter  broken  in  with  the  forceps,  before 
the  root  is  removed.  The  compound  screw  is  often 
very  valuable  in  the  removal  of  these  roots, — the  sim- 
ple screw  not  commonly  being  of  much  avail,  since 
i  he  force  necessary  to  extract  the  root  is  generally  so 
great  that  the  screw  alone  will  not  take  a  sufficiently 
firm  hold  to  accomplish  it.  The  elevator  is  not  a  very 
efficient  instrument  in  the  removal  of  these  roots. 

Superior  Bicuspids. — For  the  removal  of  the  bicus- 
pid teeth  of  both  Bides,  one  pair  of  forceps  is  quite 
sufficient.   (See  Fig.  102.)     These  forceps  are  without 


410  EXTRACTION   OF  TEETH. 

any  curve;  though  in  a  small  mouth,  for  the  second 
bicuspids,  a  slight  anterior  curve  would  be  desirable, 
since  it  would  admit  the  instrument  to  a  better  posi- 
tion on  the  tooth.  These  forceps  properly  adjusted 
on  the  tooth,  according  to  the  directions  already  given, 
the  attachment  is  broken  up  by  an  inward  and  out- 
ward movement,  carried  just  to  the  extent  necessary 
to  accomplish  the  object;  and  then  traction  is  applied 
to  remove  the  tooth  from  the  socket.  This  applica- 
tion of  the  force  is  specially  adapted  to  the  first  bicus- 
pids. Rotary  motion  should  be  very  seldom  applied 
to  these  teeth,  because  their  points  generally  terminate 
in  a  bifurcation,  and  it  is  impracticable  thus  to  detach 
them  without  breaking  off  at  least  one  of  the  roots; 
and  where  they  do  not  bifurcate,  they  are  so  much 
compressed  as  generally  to  forbid  such  a  force.  Occa- 
sionally, however,  there  is  but  one  root,  and  this  is 
nearly  cylindrical,  as  will  be  indicated  by  the  cylin- 
drical form  of  the  crown  and  neck  of  the  tooth  ;  and 
in  such  cases  the  rotary  may  be  combined  with  the  in- 
ward and  outward  motion.  The  root  of  the  second 
bicuspid  commonly  has  no  bifurcation,  and  is  usually 
somewhat  compressed  ;  and,  in  general,  the  rotary  mo- 
tion may  be  combined  with  the  inward  and  outward 
in  its  extraction.  There  is  occasionally,  however,  some 
curvature  to  the  roots  of  these  teeth  ;  but  very  seldom 
is  it  sufficient  to  cause  any  difficulty  in  their  removal. 
The  skilful  and  experienced  operator  will  in  most  cases 


EXTRACTION    OF   TEETH.  411 

determine  very  accurately  the  size,  shape,  and  position 
of  the  roots  by  the  peculiarities  of  the  crown  ;  and  the 
attention  of  the  young  practitioner  should  be  directed 
very  closely  to  this  point,  till  he  is  able  to  arrive  at 
accurate  conclusions.  For  the  removal  of  these  teeth, 
there  are  forceps  with  thick,  peculiarly-formed  beaks, 
constructed  to  take  advantage  of  the  conical  shape  of 
the  roots.  The  instrument  is  placed  on  the  tooth  at 
the  border  of  the  alveolus,  or,  if  need  be,  a  little  be- 
yond it;  and  then,  the  process  having  been  first  cut 
away,  firm  compression  is  made  on  the  handle  of  the 
instrument,  and  thus  great  pressure  on  two  opposite 
sides  of  the  root, — which  are  relatively  as  two  inclined 
planes, — by  which  the  tooth  is  forced  directly  from  its 
socket,  without  either  the  oscillating  or  the  rotary  mo- 
tion. This  instrument  is  rarely  ever  applicable  to  the 
removal  of  any  other  teeth  than  the  second  bicuspids, 
and  occasionally  the  central  incisors,  and  then  only 
when  the  roots  are  very  tapering.  The  roots  of  the 
bicuspids,  especially  the  second,  are  usually  not  difficult 
to  remove.  Sometimes,  however,  the  first  bicuspids 
have  two  well-formed  roots,  somewhat  divergent,  that 
are  difficult  to  remove,  especially  if  the  decay  has  eaten 
away  till  there  is  little  of  the  tooth  left  for  the  instru- 
ment to  take  hold  upon.  But,  frequently,  if  one  of 
the  contiguous  teeth  is  absent,  a  lateral  seizure  will 
remove  the  root  at  once. 

Root  forceps  with  narrow,  thin   beaks,  which   may 


412  EXTRACTION   OF   TEETH. 

be  readily  forced  between  the  root  and  the  alveolus, 
are  very  valuable  for  the  extraction  of  all  small  roots. 

The  screw,  whether  simple  or  compound,  is  not  ap- 
plicable to  the  extraction  of  the  roots  of  the  bicuspids. 

A  bicuspid  will  sometimes  stand  somewhat  out  of 
the  true  circle,  and  the  contiguous  teeth  approximate 
so  that  it  will  not  pass  between  them.  In  such  a  case, 
the  principal  part  of  the  movement  for  its  detachment 
should  be  in  the  direction  of  its  inclination.  The  cus- 
pid teeth  are  sometimes  found  in  the  same  condition, 
and  a  similar  amplication  of  force  for  their  removal  is 
to  be  made ;  indeed,  this  method  is  appropriate  to  all 
cases  where  the  teeth  stand  out  of  a  proper  position, 
and  the  contiguous  teeth  impinge  on  the  space. 

Superior  Molars. — The  first  and  the  second  superior 
molars  have  each  three  roots,  one  palatal,  and  two 
buccal ;  the  palatal  being  the  largest  and  longest,  and 
the  anterior  buccal  larger  than  the  posterior.  The 
palatal  root  diverges  very  considerably  from  the  axis 
of  the  tooth,  while  the  buccal  are  often  parallel  with 
it  and  with  each  other  ;  but  they  sometimes  diverge 
in  both  directions.  Occasionally  the  divergence  of 
some  or  all  of  these  roots  is  so  great,  that  they  can- 
not pass  out  of  the  socket  without  either  fracturing  the 
alveolus  or  breaking  off  one  or  more  of  the  roots.  On 
the  contrary,  there  is  sometimes  such  a  convergence 
of  the  buccal  roots,  that  the  intervening  portion  of 
bone  is  necessarily  brought  away  with  the  tooth.     In- 


EXTRACTION    OF   TEETH.  413 

deed,  the  three  roots  are  sometimes  found  all  in  con- 
tact, forming  an  irregular  conical  root ;  but  this  is  a 
condition  of  unnatural  development. 

The  appropriate  forceps  being  firmly  fixed  on  the 
tooth,  an  outward  and  inward  movement  is  applied, 
and  traction  at  the  same  time.  In  the  examination 
of  these  teeth,  to  ascertain  the  force  necessary  for 
their  removal,  two  particulars  have  to  be  considered: 
the  firmness  of  the  attachment,  and  the  position  and 
inclination  of  the  roots.  When  these  teeth,  as  they 
occasionally  do,  stand  somewhat-  outside  of  the  cor- 
rect position,  great  care  must  be  exercised  in  their 
removal,  especially  if  the  contiguous  teeth  impinge. 
In  small  mouths,  the  contiguous  impinging  tooth  is 
liable  to  be  injured  by  the  pressure  in  extraction  ;  but 
this  injury  may  be  avoided  by  directing  the  pressure 
backward. '  Commonly,  the  first  effort  made  to  break 
up  the  attachment  should  be  outward,  excej)t  where 
the  tooth  stands  inside  the  circle,  or  where  it  is  de- 
cayed very  much  on  its  inner  side,  while  its  outer 
remains  firm.  In  those  cases  in  which  the  roots  di- 
verge so  much  that  they  will  not  pass  out  of  the  socket 
without  tearing  away  some  of  the  wall  of  the  alveo- 
li is,  it  would  be  impossible  to  break  up  the  attach- 
ment by  an  inward  movement,  for  the  palatal  root 
braces  the  tooth,  and  the  inner  process  is  very  strong 
and  unyielding.  Where  a  molar  has  decayed  on  its 
proximate  sides,  and  the  contiguous  teeth  encroach  on 


414  EXTRACTION   OF   TEETH. 

it,  so  that  it  cannot  pass  out  directly  between  tliein,  it 
must  either  be  cut  away  with  the  chisel,  file  or  disk, 
till  it  is  small  enough  to  pass  out,  or  be  drawn  from 
between  them. 

The  decay  on  the  buccal  or  palatal  sides  often  ex- 
tends below  the  gum,  and  even  below7  the  border  of 
the  alveolus ;  or  there  may  be  extensive  softening  of 
the  dentine  of  the  crown  ;  in  either  case,  the  gum  and 
process  must  be  cut  away  sufficiently  to  admit  a  firm 
hold  on  the  root  where  it  is  strong  enough  to  sustain 
the  embrace  of  the  forceps. 

Extraction  of  Roots. — The  extraction  of  the  roots 
of  the  superior  molars  is  not  attended  with  much 
difficulty  when  they  are  separated  by  decay,  or  are 
easily  broken  apart ;  the  method  then  is  the  same  as 
for  single  roots.  They  should  be  deeply  embraced 
with  the  curved,  sharp-pointed  root  forceps  (see  Fig. 
107),  and  rotated  to  break  up  the  attachment,  trac- 
tion being  applied  at  the  same  time.  It  is  very  rarely 
necessary  to  resort  either  to  the  elevator  or  to  the 
screw  for  the  removal  of  these  roots.  The  greatest 
difficulty  is  experienced  when  the  bifurcation  is  deep 
and  the  roots  all  adhere  firmly  together.  In  such  case, 
the  same  force  is  required  for  their  removal  as  before 
the  crown  was  decayed  off.  The  root  forceps,  shown 
in  Fig.  104,  can  be  very  effectively  used  in  the  extrac- 
tion of  these  roots.  The  round  sharp  beak  is  passed 
between  the  buccal  roots,  the  other  beak  embracing 


EXTRACTION    OF   TEETH.  415 

the  palatal ;  and  with  this  hold,  by  an  inward  and 
outward  movement,  the  root  is  removed.  These  forceps 
are  not  applicable  where  there  is  but  one  large  conical 
root.  For  the  removal  of  roots  of  this  form,  the  third 
molar  forceps,  or  those  with  similar  beaks,  are  required. 
When  it  is  necessary  to  dissect  off  the  gum,  and  cut 
away  the  process,  in  order  to  obtain  a  firm  hold  of 
the  root,  this  should  be  done  in  preference  to  crushing 
in  the  j:>rocess  with  forceps — except,  indeed,  it  may 
be  the  case  of  a  very  irritable  patient,  who  will  not 
tolerate  a  protracted  operation,  in  which  case  it  is 
better  to  complete  the  operation  at  a  single  effort. 

Third  3/olars. — There  is  not  usually  much  difficulty 
attending  the  extraction  of  these  teeth.  The  appro- 
priate forceps  for  this  purpose  (see  Figs.  105  and  111) 
have  two  large  single-concave  beaks,  so  formed  as  to 
embrace  the  neck  of  the  tooth,  without  any  reference 
to  the  bifurcation  or  the  number  and  position  of  the 
roots.  Ordinarily,  the  attachment  of  these  teeth  is 
broken  up  by  the  inward  and  outward  movement;  but 
where  a  single,  round,  conical  root  is  clearly  indicated, 
the  rotary  movement  would  be  preferable,  or  the  ro- 
tary in  conjunction  with  the  inward  and  outward. 
These  teeth  sometimes  stand  out  of  the  true  position, 
more  frequently  inclining  outward,  as  already  sug- 
ted  in  another  place;  and  the  direction  of  the  force 
for  their  extraction  will  correspond  with  this  inclina- 
tion. 


416  EXTRACTION    OF   TEETH. 

Sometimes  these  teeth  are  very  difficult  to  extract; 
and  this  difficulty  is  dependent  on  the  following  cir- 
cumstances :  first,  an  anterior  inclination  of  the  tooth, 
•so  that  it  stands  at  a  considerable  angle  with  the 
adjoining  tooth,  and  in  contact  with  its  posterior 
proximate  surface,  the  posterior  border  of  the  process 
being  thick  and  firm,  and  extending  down  full  on 
the  crown  of  the  tooth ;  and  second,  the  existence  of 
several  roots,  with  great  divergence,  irregularity,  and 
curvature.  The  removal  of  a  tooth  in  the  first  of 
these  conditions  is  often  a  very  protracted  operation, 
fraught  with  much  pain  to  the  patient  and  consider- 
able labor  to  the  operator.  Such  preparation  must 
be  made  as  will  permit  a  free  egress  of  the  tooth  from 
the  socket,  before  an  effort  is  made  for  its  extraction. 
This  is  effected  either  by  cutting  away  the  portion  of 
process  behind  the  tooth,  so  that  it  may  be  forced 
backward  sufficiently  to  let  it  pass  out  of  the  socket, 
or  by  cutting  away  enough  from  the  anterior  portion 
of  the  tooth ;  or,  if  the  posterior  proximate  sur- 
face of  the  second  molar  is  decayed,  it  may  be  quite  as 
well,  and  more  convenient,  to  cut  this  down  so  as  to 
permit  the  ready  removal  of  the  tooth. 

Physic's  forceps  can  be  used  very  effectively  for  the 
extraction  of  these  teeth  when  they  occupy  such  a 
position,  provided  the  root  is  straight,  or  has  a  poste- 
rior curvature  ;  but  if  there  is  an  anterior  curvature, 
the  tooth  is  most  difficult  to  extract,  and  Physic's  for- 


EXTRACTION    OF   TEETH.  417 

ceps  would  he  wholly  inefficient,  except  to  break  off 
the  tooth.  In  such  case,  the  posterior  portion  of  the 
process  should  be  cut  away  as  much  as  possible. 
Physic's  forceps  are  frequently  employed  for  the  re- 
moval of  these  teeth  when  they  occupy  a  correct  posi- 
tion ;  but  their  use  is  somewhat  objectionable,  especially 
in  the  following  respects.  The  instrument  acts  first 
on  the  principle  of  a  wedge,  being  forced  between  the 
teeth  ;  and  then  on  that  of  a  lever,  the  second  molar 
being  the  fulcrum ;  and  hence,  when  it  is  employed, 
the  second  molar  must  always  be  present,  and  is  liable 
to  injury  from  the  pressure,  which  may  do  violence  to 
the  periosteum,  or  fracture  and  scale  off  portions  of  the 
enamel.  But  if  the  first  molar  is  absent,  there  is  almost 
as  much  liability,  with  the  Physic's  forceps,  of  loosen- 
ing the  second  as  of  extracting  the  third.  Indeed,  it  is 
always  objectionable  to  use  a  sound  tooth,  under  any 
circumstances,  as  a  fulcrum  for  an  extracting  instru- 
ment. 

A  third  molar  the  roots  of  which  are  irregular  in 
number,  inclination,  and  curvature,  should  be  grasped 
firmly,  and  an  oscillating  force  applied  sufficient  tore- 
move  it  from  its  socket.  There  is  nothing  pertaining 
to  the  removal  of  the  roots  of  these  teeth  that  involves 
any  dinerenl  principle  or  application  of  instruments 
from  that  iriven  for  the  removal  of  the  teeth  themselves. 
The  anterior  inclination,  which  so  often  renders  the 
whole  tooth  difficult  of  extraction,  very  seldom  affects 

Ti 


418  EXTRACTION   OF   TEETH. 

the  removal  of  the  roots.  These  are,  in  general,  easily 
extracted  with  the  common  curved  root-forceps. 

Inferior  Incisors. — In  the  extraction  of  these  teeth, 
either  of  the  forceps  described  for  the  purpose  may  be 
employed.  The  beaks  should  be  quite  narrow  and 
thin  (see  Fig.  100).  The  instrument  well  fixed  on  the 
tooth,  the  attachment  is  broken  up  by  an  inward  and 
outward  movement,  the  rotary  being  seldom  applicable, 
since,  in  general,  the  roots  are  flattened,  and  in  many 
cases  quite  thin,  so  as  to  be  incapable  of  turning  in  the 
socket.  Care  must  be  exercised  in  the  oscillating 
movement,  and  especially  where  the  tooth  to  be  ex- 
tracted stands  out  of  the  proper  position,  and  the  con- 
tiguous teeth  incline  together ;  though  this  is  of  little 
consequence  where  the  teeth  are  all  to  be  removed. 
When  the  crowns  of  these  teeth  are  short  and  thick, 
the  roots  are  shorter,  thicker,  more  conical,  and  more 
nearly  cylindrical ;  and  in  the  extraction  of  such  the 
rotary  may  be  combined  with  the  oscillating  move- 
ment. 

There  is  seldom  any  superadded  difficulty  in  the  re- 
moval of  the  roots  of  these  teeth,  the  same  instruments 
and  movements  being  applicable  as  for  the  removal  of 
the  teeth  themselves.  The  only  difference  in  any  re- 
spect is,  that  where  the  teeth  are  decayed  off  far  down, 
the  forceps  should  be  forced  down  on  the  process,  in 
order  to  obtain  a  firm  hold  on  the  root.     Neither  the 


EXTRACTION   OF   TEETH.  419 

elevator  nor  the  screw  is  ever  required  for  the  removal 
of  these  roots. 

Inferior  Cuspids. — These  teeth  may  be  removed 
with  the  inferior  bicuspid  forceps  of  the  right  side, 
though  an  instrument  of  the  same  general  form,  but 
of  less  curvature,  would  be  preferable,  since  with  such 
the  required  movement  for  breaking  up  the  attach- 
ment could  be  more  easily  given.  They  commonly 
have  long,  round,  conical  roots,  not  so  large  as  those 
of  the  superior  cuspids,  nor  so  difficult  to  extract,  sel- 
dom having  any  curvature,  and  thus  being  susceptible 
of  detachment  by  the  rotary  motion.  They  often 
.stand  so  much  anterior  to  the  true  circle,  that  an  at- 
tempt to  thrust  them  inward  would  be  liable  to  break 
or  loosen  the  lateral  incisors.  Their  situation,  as  in- 
deed that  of  all  teeth,  should  be  fully  comprehended 
before  any  attempt  is  made  to  remove  them. 

The  crowns  of  these  teeth  decay  off,  and  leave  the 
roots  standing,  far  more  frequently  than  do  those  of 
the  superior  cuspids.  But  there  is  no  difficulty  in  the 
removal  of*  their  roots,  and  the  only  indication  is,  when 
they  are  deeply  decayed,  to  pass  the  forceps  far  down 
on  them,  either  lirsi  cutting  a  way  the  process  or  em- 
bracing  it,  as  the  circumstances  may  warrant,  the 
former  method  being  preferable.  After  the  root  is 
extracted,  the  fractured  pieces  of  process,  if  any,  should 
be  removed. 

A   long,  tapering  screw  may  sometimes  be  advan- 


420  EXTRACTION   OF   TEETH. 

tageouslv  used  for  the  extraction  of  these  root>,  when 
they  are  decayed  so  deeply  that  an  extensive  breaking 
away  of  the  process  would  be  incident  to  their  removal 
with  the  forceps.  The  elevator,  however,  is  rarely  ever 
called  into  requisition  here. 

Inferior  Bicuspids. — These  teeth,  two  in  number, 
on  each  side,  have  but  one  root  each,  and  that  gener- 
ally round,  or  nearly  so,  and  not  so  long  as  that  of  the 
cuspids,  and  have  less  diameter  at  the  neck.  They  re- 
quire, in  extraction,  forceps  for  each  side,  as  already 
described  (see  Fig.  108).  They  may  be  removed  either 
by  the  rotary  or  by  the  inward  and  outward  move- 
ment, or  both  combined.  With  the  handle  of  the  for- 
ceps thrown  very  far  out  of  a  line  with  the  axis  of  the 
tooth,  it  is  always  more  difficult  to  be  rotated  accu- 
rately in  its  socket ;  a  straight  instrument  is  best  for 
the  rotary  motion.  In  the  removal  of  these  teeth 
from  the  right  side,  when  the  mouth  is  small,  care 
should  be  taken  that  too  much  pressure  is  not  made 
against  the  anterior  tooth.  This  accident  is  more 
liable  to  happen  in  the  removal  of  the  second  bicus- 
pid than  in  that  of  the  first,  and  especially  if  the 
mouth  cannot  be  opened  wide.  As  the  tooth  comes 
out  the  forcei^s  are  liable,  without  some  attention,  to 
strike  the  superior  teeth,  and  in  this  way  fracture 
them  or  scale  off  their  enamel.  In  many  cases,  for- 
ceps with  a  forward  and  outward  curvature  com- 
bined  would    be   very  desirable   for    facility  of  ap- 


EXTRACTION   OF   TEETH.  421 

proaching  the  tooth ;  but  with  such  a  complication 
of  curves  the  operator  loses  control  of  the  instru- 
ment. 

In  the  removal  of  the  bicuspids  of  the  left  side, 
there  is  little  or  no  liability  to  undue  pressure  against 
the  anterior  teeth  ;  and  in  their  extraction  the  move- 
ment should  be  mainly  inward  and  outward,  since 
the  great  curvature  of  the  forceps  renders  a  rotary 
motion  very  difficult  and  uncertain.  There  is  also 
danger  of  striking  the-  upper  teeth,  esj)ecially  if  the 
tooth  to  be  extracted  comes  out  with  less  effort  than 
the  operator  anticipated — an  accident  that  sometimes 
befalls  the  most  skilful  and  discriminating.  The 
first  and  the  second  inferior  bicuspids  are  removed 
with  about  equal  facility. 

Occasionally,  though  seldom,  these  teeth  have  two 
distinct,  well-defined  roots — a  condition  that  cannot  be 
determined  by  the  form  of  the  crown,  or  by  any  other 
visible  indication;  and  one  tooth  alone  will  sometimes 
be  found  with  this  peculiarity.  The  removal  of  the 
roots  of  these  teeth  is  not  attended  with  much  diffi- 
culty, the  main  consideration  being  to  obtain  a  deep, 
strong  hold  on  them,  and  then  apply  a  firm  steady 
movement. 

Inferior  Molars. — These  teeth  commonly  have  two 
loots,  a  posterior  and  an  anterior,  the  latter  being  the 
largest,  and  frequently  the  longest.  The  roots  have 
different  inclinations  to  the  axis  of  the  tooth,  being 


422  EXTRACTION   OF  TEETH. 

in  some  eases  divergent  from,  and  in  others  parallel 
with  it,  and  in  others  convergent,  or  curved  together 
so  that  their  points  almost  meet.  The  forms  of  the 
crowns  will  give  some  indication  of  the  inclinations 
of  the  roots.  If  the  former  are  short,  the  latter  are 
so,  and  vice  versa,  if  the  diameter  of  the  crown  is  about 
the  same  at  the  masticatory  surface  and  the  neck,  the 
roots  do  not  diverge ;  if  the  crown  is  long  and  of 
uniform  diameter,  the  roots  will  be  either  parallel 
or  convergent,  and,  if  the  angles  on  the  crown  are 
not  sharp  and  well-defined,  the  roots  most  probably 
curve  together  at  the  points.  If,  however,  the  an- 
gles formed  by  the  masticatory  and  lateral  surfaces  of 
the  teeth  are  sharp  and  well-defined,  the  roots  gener- 
ally diverge. 

Forceps  adapted  to  each  side  are  required  for  the 
removal  of  these  teeth.  These  forceps  have  a  promi- 
nence, or  point,  in  the  centre  of  the  beaks,  to  pass 
into  the  bifurcation;  and  in  sej^arating  the  gum  it  is 
important  to  dissect  it  away,  and,  if  need  be,  even  cut 
away  the  margin  of  the  process,  so  that  the  bifurca- 
tion may  be  well  exposed,  to  admit  the  forceps  to  a 
proper  position  on  the  tooth  without  obstruction.  The 
tooth  being  firmly  grasped  in  the  proper  manner  by 
the  forceps,  is  moved  gradually,  but  steadily,  inward 
and  outward,  to  break  up  the  attachment,  and  then 
drawn  from  its  socket.  In  the  removal  of  these  teeth 
from  the  right  side,  with  the  ordinary  forceps,  there 


EXTRACTION   OF   TEETH.  423 

is  great  danger  of  undue  pressure  on  the  anterior  con- 
tiguous teeth;  this  is  to  be  avoided  by  directing  the 
pressure  backward  in  the  operation.  And  there  is 
also  danger  of  injuring  the  upper  teeth  with  the  for- 
ceps; this  may  be  obviated  by  wrapping  the  point  of 
the  instrument  with  a  small  napkin. 

In  the  removal  of  the  inferior  molars  of  the  left 
side,  the  application  of  force  is  the  same — an  inward 
and  outward  movement — but  the  handles  of  the  for- 
ceps occupy  different  relative  positions  to  the  teeth  to 
be  extracted — passing  directly  out  at  the  front  of  the 
mouth  instead  of  at  one  side.  In  consequence  of  this 
arrangement,  the  operator  cannot  exert  the  same  force 
on  them  as,  with  the  proper  forceps,  on  those  of  the 
right  side.  Very  little  traction  can  be  employed  in 
connection  with  the  oscillating  movement,  but  the 
attachment  must  be  almost  wholly  broken  up  before 
beginning  to  lift  the  tooth  from  the  socket.  But,  in 
extracting  the  teeth  on  the  right  side,  with  the  proper 
forceps,  traction  is  always  combined  with  the  inward 
and  outward  movement. 

In  the  extraction  of  the  roots  of  these  teeth,  little 
difficulty  is  experienced  after  the  decay  has  proceeded 
bo  far  as  to  effect  their  separation.  They  are  then 
embraced  with  the  appropriate  forceps,  and  removed 
ae  single  roote  are  elsewhere.  The  forceps  have  nar- 
row, thin,  sharp  beaks,  turn  to  almost  a  right  angle. 
With  them  the  root  is  embraced  and  moved  inward 


424  EXTRACTION*    OF   TEETH. 

and  outward  till  loosened,  <rin<l  then  removed.  When 
the  month  is  large,  a  in  1  ••mi  beopened  wide,  the  slightly 
curved  root  forceps  are  convenient,  and  the  rotary 
movement  may  be  employed  with  them,  if  the  roots  are 
not  very  much  curved,  flattened  or  firmly  set.  The 
removal  of  these  roots  is  more  difficult  when  the  bi- 
furcation is  low  down,  and  the  roots  remain  firmly 
attached  together,  and  especially  when  they  diverge. 
If  the  bifurcation  is  not  too  low,  and  the  attachment 
not  too  firm,  the  roots  may  be  separated  with  the  sep- 
arating forceps  (Fig.  124),  and  then   removed  singly 

Fig.  124. 


as  in  other  cases.  This  is  the  preferable  method  when 
there  is  much  divergence ;  but  if  the  roots  cannot  be 
separated,  they  may  be  extracted  with  the  forceps 
shown  in  Fig.  112.  The  round,  curved,  sharp  beaks 
are  passed  down  between  the  roots,  and  the  whole  is 
removed  at  once ;  the  attachment  being  broken  up  on 
the  principle  already  described. 

These  teeth  sometimes  have  but  one  large,  round, 
conical  root ;  and  there  is  seldom,  if  ever,  enough 
curvature  of  the  roots  to  render  extraction  difficult. 
The  ordinary  inferior-molar  forceps  are  not  well 
adapted  for  the  purpose,  for  the  central  points  of  their 


EXTRACTION    OF    TEETH.  425 

beaks  will  prevent  a  perfect  adaptation.  The  broad, 
single-concave  beaked  forceps  are  best  adapted,  the 
curves  and  general  forms  of  which,  except  the  beaks, 
are  the  same  as  those  represented  in  Fig.  111.  The 
removal  of  teeth  having  roots  of  this  kind  is  easily 
accomplished.  Rotary  movement  would  be  applicable 
here  if  the  exact  form  of  the  root  could  be  ascertained 
before  extraction ;  but  it  is  in  general  the  safest  course 
to  employ  the  inward  and  outward  movement. 

Inferior  Third  Molars. — These  teeth  require  for 
their  removal  the  broad,  single-concaved  beaked  for- 
ceps, the  beaks  curved  at  nearly  a  right  angle  with  the 
handle,  and  the  handle  straight.  This  instrument  fixed 
deeply  and  firmly  on  the  tooth,  the  attachment  is  to  be 
broken  up  by  the  inward  and  outward  movement. 
These,  more  frequently  than  the  superior  third  molars, 
stand  out  of  the  proper  position  ;  their  variations  and 
the  manner  of  obviating  the  attendant  difficulties, 
however,  being  about  the  same — at  least,  so  far  as 
deviation  is  concerned.  Physic's  forceps  may  be  used 
here  with  greater  facility  than  on  the  upper  teeth. 

These  teeth  frequently  exhibit  but  a  very  small 
portion  of  the  crown  through  the  gum.  Being  erupted 
witli  an  anterior  inclination,  the  tooth  comes  in  contact 
with  the  posterior  portion  of  the  second  molar,  and  is 
thus  checked  in  its  external  development.  Thus  the 
ciown  is  loft  partially  covered  with  the  gum,  which 
frequently  inflames,,  and  even  suppurates,  remaining 


426  EXTRACTION    OF   TEETH. 

in  that  condition  for  a  considerable  time,  to  the  great 
annoyance  of  the  patient.  Such  teeth  are  difficult  to 
remove;  first,  because  of  their  inclination  and  contact 
with  the  second  molar;  and  secondly,  because  the 
crown  is  more  than  half  below  the  borders  of  the  thick, 
firm,  alveolus,  rendering  it  impossible  to  obtain  a  firm 
hold  on  the  tooth  without  cutting  away  a  portion  of 
the  alveolus.  In  such  cases,  it  is  generally  best  to  make 
a  free  excision  of  the  alveolus  all  round  the  tooth, 
sufficient  to  permit  its  easy  removal. 

Extraction  Preparatory  to  the  Insertion  of 
Artificial  Dentures. 

Whenever  there  is  a  number  of  teeth  to  be  removed, 
the  method  and  the  duration  of  the  operation  will  de- 
pend on  the  following  circumstances  : 

First.  The  number  to  be  removed. 

Second.  The  firmness  of  their  attachment. 

Tli  ird.  The  patient's  powrer  of  endurance. 

Fourth.  The  manner  in  wdiich  the  immediate  parts 
are  affected. 

Where  the  number  to  be  removed  is  considerable, 
and  the  attachment  feeble,  or  not  very  firm,  and  the 
patient's  power  of  endurance  good,  the  extraction 
may  be  as  rapid  as  is  consistent  with  efficiency.  In 
many  such  cases,  from  three  to  six  teeth  may  be  re- 
moved, without  any  relaxation  by  the  operator  of  his 


FOR    INSERTION    OF    ARTIFICIAL    DENTURES.  427 

hold  on  the  parts  with  the  left  hand.  This  is  gener- 
ally practicable  with  the  front  teeth  of  the  lower,  and 
frequently  with  those  of  the  upper  jaw ;  but  it  is  not 
proper  to  remove  more  than  three  or  four  of  the  molar 
teeth  without  respite,  even  when  they  are  quite  loose, 
or  have  but  a  feeble  attachment  in  the  socket.  The 
gum  should,  of  course,  be  well  separated  previously  to 
the  operation.  Only  so  many  teeth  should  be  removed 
at  one  sitting  as  the  nervous  system  will  allow  without 
too  great  a  shock.  In  many  instances,  however,  it  is 
practicable,  so  far  as  this  is  concerned,  to  remove  at 
once  all  the  teeth  in  the  mouth.  In  the  extraction  of  a 
large  number,  those  most  easily  removed  should  be  first 
taken,  so  as  by  degrees  to  bring  the  patient  to  the  more 
severe  operations.  If  there  is  a  manifest  hemorrhagic 
diathesis — a  disposition  to  bleed  freely  from  the  capil- 
laries, as  well  as  from  the  larger  vessels — but  two  or 
three  teeth  should  be  removed  at  a  sitting,  lest  uncon- 
trollable haemorrhage  ensue. 

After  all  the  teeth  are  removed  from  one  or  both  of 
the  jaws,  the  gums  and  alveolus  should  undergo  a 
trimming  process  :  all  detached,  flabby,  or  prominent 
portions  of  the  gums  should  be  dissected  off;  the  whole 
ridge  made  uniform  ;  all  loose  portions  of  the  alveolus 
removed  ;  all  the  prominent  points  and  sharp  edges 
cut  down  ;  and  the  whole  border  of  the  process  ren- 
dered  as  smooth  and  even  as  possible.  By  this  means, 
the  healing  of  the  parts  ie  facilitated,  and  they  assume 


428  EXTRACTION   OF   TEETH. 

the  desired  condition  and  form  in  much  less  time,  and 
with  far  Less  soreness  and  inconvenience. 


Conditions  to  be  Observed  in  Extraction. 

Such  conditions  are  often  found  to  exist  in  the  sys- 
tem as  indicate  the  necessity  of  great  care  in  the  ope- 
ration, or  of  prior  treatment,  or  forbid  the  extraction 
<  )f  the  teeth  altogether.  Of  these  conditions,  the  follow- 
ing are  some  of  the  more  obvious : 

Extreme'debility. 

Great  nervous  irritability. 

Excessive  local  inflammation,  especially  where  it 
tends  to  other  parts. 

Much  irritability  of  the  parts  intimately  connected 
with  the  teeth. 

Pregnancy  and  all  uterine  irritations. 

A  tendency  to  epilepsy. 

In  many  cases,  where  there  is  great  debility,  so  pain- 
ful an  operation  as  the  extraction  of  a  tooth  will  cause 
extreme  and  sometimes  alarming  prostration.  This, 
however,  may  be  anticipated  by  prior  invigorating 
treatment,  continued  till  strength  and  tone  are  obtained 
sufficient  to  endure  the  operation.  This  treatment 
may  occupy  considerable  time,  while  an  urgent  case 
may  arise,  in  which  the  removal  of  the  offending  tooth 
is  immediately  demanded,  in  which  case  it  is  proper  to 
administer  stimulants; — brandy  or  wine,  or  such  as  the 


CONDITIONS   TO    BE    OBSERVED    IN    EXTRACTION.       429 

case  may  seem  to  require.  By  sucli  means  the  system 
may  be  so  invigorated  as  to  withstand  the  shock  of  the 
operation  with  comparative  fortitude. 

There  is  in  some  cases  a  highly  irritable  condition  of 
the  nervous  system,  that  almost  absolutely  forbids  the 
extraction  of  teeth,  convulsions  being  sometimes  pro- 
duced in  such  cases  by  a  simple  operation.  This  re- 
mark does  not  of  course  apply  to  facial  neuralgia,  that 
may  be  either  partially  or  wholly  produced  and  kept 
up  by  diseased  teeth  ;  neither  general  nor  local  neu- 
ralgia would  be  aggravated  by  an  operation  of  this 
kind.  Accompanying  general  nervous  irritability, 
there  is  usually  excessive  dread  of  an  operation,  such 
as  to  occasion  rapid  prostration — even  greater  and  more 
rapid  than  that  caused  by  the  operation  itself.  In  such 
3,  if  the  extraction  is  effected  immediately,  it  will 
give  relief;  but  where  the  excitement  has  been  very 
high,  and  the  tension  for  some  time  great,  the  depres- 
sion after  the  operation  will  be  correspondingly  great, 
and  considerable  time  be  required  for  complete  recov- 
ery ;  indeed,  the  shock  is  sometimes  so  severe  as  to 
occasion  confinement  for  several  days.  Treatment  for 
quieting  the  nervous  system,  consisting  in  agents  of  a 
sedative  character,  may  be  employed  previously  to  the 
operation.  Stimulants,  as  a  general  rule,  should  be 
;iv<ii<l<-d. 

Where  there  ie  n  high  state  of  inflammation  in  the 
immediate  parts,  especially  it'  there  is  a  general  inllam- 


430  EXTRACTION  OF   TEETH. 

niatory  diathesis,  the  propriety  of  extracting  the  teeth 
is  questionable.  Under  such  circumstances,  there  is 
probably  less  danger  in  the  extraction  of  the  inferior 
teeth  than  of  the  superior.  Where  the  inflammation 
has  a  disposition  to  extend,  it  is  liable  to  go  to  the 
head  from  the  superior  maxilla,  and  to  the  fauces  and 
throat  from  the  inferior.  In  cases,  then,  where  there 
is  excessive  inflammation  in  the  immediate  parts,  ac- 
companied by  a  general  inflammatory  condition,  both 
local  and  general  antiphlogistic  treatment  should  be 
adopted 

Extreme  irritability,  or  a  diseased  condition  of  parts 
having  an  intimate  connection  with  the  teeth,  as,  the 
immediate  surrounding  tissues,  the  salivary  glands, 
and  the  throat,  is  a  circumstance  admonishing  to  great 
caution  in  the  extraction  of  teeth,  especially  when  such 
condition  does  not  depend  on  the  teeth  for  its  exciting 
cause  or  modifying  influence.  It  is,  however,  very 
generally  the  case,  when  any  of  the  parts  having  an 
intimate  relation  with  the  teeth  become  in  any  way 
affected,  that  diseased  teeth  will  exercise  an  inju- 
rious influence  on  them.  If  the  necessity  for  the  re- 
moval of  the  offending  tooth  is  not  too  urgent,  the  parts 
that  may  be  diseased  about  it  should  be  brought  to  as 
good  a  condition  as  possible. 

Pregnancy  and  uterine  irritation  frequently  produce 
strong  sympathetic  influences  on  the  teeth,  and  espe- 
cially on  those  which  are  in  an  irritable  condition.  Even 


CONDITIONS   TO    BE   OBSERVED   IN    EXTRACTION.       431 

sound  teeth  may  be  thus  affected,  so  as  to  occasion 
great  annoyance.  Such  teeth  are  frequently  presented 
for  extraction  ;  but  these  cases  should  always  be  thor- 
oughly examined  before  deciding  as  to  the  propriety 
of  an  operation.  As  a  consequence  of  this  sympathetic 
connection  between  the  teeth  and  the  uterus,  the  latter, 
when  in  an  irritable  condition,  is  very  liable  to  be  af- 
fected by  any  special  violence  to  the  former.  In  many 
cases,  under  such  circumstances,  the  extraction  of  a 
tooth  is  attended  with  pain  in  the  uterus;  and  in  cases 
of  pregnancy,  where  there  is  debility  of  the  parts  in- 
volved, abortion  may  follow  the  operation.  It  is  the 
duty  of  the  patient,  under  such  circumstances,  to  notify 
the  operator  of  the  condition,  or  if  the  latter  has  any 
knowledge  of  it,  it  is  his  duty  to  become  fully  ac- 
quainted with  the  circumstances,  and  then  to  conform 
to  the  indications.  In  such  case,  treatment  will  avail 
but  little  to  prepare  the  system  for  the  operation.  The 
1  utter  method  is  to  adopt  palliative  treatment,  which, 
if  the  affection  is  wholly  sympathetic,  must  be  directed 
to  the  organ  producing  the  difficulty.  But  if  the  af- 
fection is  in  part  local,  then  topical  treatment  is  also 
indicated.  When  there  is  a  suppression  of  menstrua- 
tion, there  will  be  an  increased  disposition  to  haemor- 
rhage ;  and  in  the  extraction  of  the  teeth  of  a  patient 
of  haemorrhagic  diathesis,  this  is  a  point  to  which 
attention  should  be  very  specially  directed.     Here,  of 


432  EXTRACTION   OF   TEETH. 

course,  a  remedy  for  the  obstruction  would  meet  the 
difficulty. 

Persons  subject  to  epilepsy  should  be  very  cautiously 
treated  in  all  operations  on  the  teeth,  and  most  espe- 
cially in  their  extraction.  It  is  not  probable,  how- 
ever, that  an  operation  of  this  character  would  increase 
the  tendency  to  epilepsy ;  but  any  undue  excitement 
is  liable  to  produce  a  paroxysm  of  the  disease,  and 
hence  the  operator  should  proceed  to  his  work  with  as 
little  parade  as  possible,  yet  not  stealthily  ;  the  patient 
should  be  thoroughly  aware  of  what  is  to  be  done ; 
for,  of  all  patients,  such  a  one  is  the  last  that  should 
be  deceived.  Of  course,  in  a  case  of  this  kind,  there 
can  be  no  prior  treatment  that  will  avail  anything ; 
the  most  that  can  be  done  is,  to  await  the  fittest  oppor- 
tunity in  respect  to  the  paroxysms.  There  is  no  more 
liability  to  fatal  results  with  such  patients  than  with 
others. 


CHAPTER  XII. 

ACCIDENTS    IN    THE    EXTRACTION    OF    TEETH. 

The  accidents  liable  to  occur  to  the  teeth  and  the 
contiguous  parts  in  the  operation  of  extraction  are 
much  less  frequent  and  serious  than  formerly.  This 
results  from  the  existence  of  more  perfect  instruments 
and  of  more  accurate  and  extensive  knowledge. 
Formerly,  very  few  studied  the  peculiarities  of  the 
teeth,  either  in  their  physical  or  anatomical  structure  ; 
their  peculiar  forms  as  indicated  by  their  crowns; 
their  anatomical  and  physiological  relations  to  the 
contiguous  parts,  and  to  one  another ;  and  their  at- 
tachment as  affected  by  the  character  and  structure 
of  the  tissues  about  them.  The  instruments  em- 
ployed, too,  were,  till  within  a  few  years  past,  very 
crude  in  their  forms,  very  inapplicable  in  that  part 
which  embraces  the  tooth,  inappropriate  in  their 
shapes,  and  defective  in  their  manner  of  applying 
the  force  in  the  operation.  But  these  causes  of  acci- 
dents, so  far  as  the  better  part  of  the  dental  profes- 
sion is  coiic  rued,  have  been  in  a  very  marked  degree 
diminished. 

Some  of  the  accidents  attendant  or  consequent  on 

28 


434  ACCIDENTS    IN   THE   EXTRACTION   OF  TEETH. 

the  extraction  of  teeth  are  of  a  grave  character. 
Permanent  deformity  has  sometimes  been  occasioned 
by  extensive  laceration  of  the  soft  parts,  or  by  frac- 
ture of  the  alveolus  and  of  the  maxilla.  Intense  and 
protracted  suffering  frequently,  and  death  sometimes, 
follows  such  accidents. 


HEMORRHAGE. 

Excessive  and  obstinate  haemorrhage  in  some  cases 
follows  the  extraction  of  teeth,  occasionally  resulting 
seriously  and  even  fatally.  There  is  in  some  consti- 
tutions a  hemorrhagic  diathesis,  so  that  from  a  small 
wound,  or  even  a  scratch,  there  will  ensue  persistent 
bleeding.  This  condition  is  dependent,  first,  on  a 
lack  of  tone  in  the  bloodvessels,  so  that  they  fail  to 
contract  at  an  injured  or  ruptured  point;  and  sec- 
ondly, on  a  peculiar  condition  of  the  blood,  such  as 
to  prevent  ready  coagulation,  as  when  there  is  a  rela- 
tive deficiency  of  albumen  and  fibrin.  It  is  one  of 
the  most  important  duties  that  ever  devolve  on  the 
dentist,  to  make  a  correct  diagnosis  in  cases  where 
there  is  a  tendency  to  haemorrhage.  Close  attention 
to  the  following  points  will  assist  much  in  arriving 
at  a  just  conclusion.  In  persons  of  a  hemorrhagic 
tendency  there  is  a  lymphatic,  serous  temperament; 
a  lack  of  tone  in  the  soft  parts,  a  soft  flabby  condi- 
tion ;  the  skin  pale,  and  devoid  of  the  bright,  vital 


HEMORRHAGE.  435 

appearance  ;  the  eyes  and  hair  of  light  color ;  and 
the  flow  of  saliva  and  mucus  abundant.  Besides  these 
indications,  much  may  be  learned  sometimes  by 
properly-directed  inquiries  of  the  patient  in  regard 
to  a  disposition  to  haemorrhage  on  being  wounded, 
either  in  his  own  case,  or  in  that  of  his  relatives ;  if 
in  the  former,  under  what  circumstances;  whether 
from  an  extensive  or  slight  wound;  from  large  or 
small  vessels,  from  arteries  or  veins ;  or  whether  it 
occurred  immediately  or  after  the  lapse  of  some  time. 
If  the  patient  has  never  met  with  an  accident  suffi- 
cient to  occasion  excessive  haemorrhage,  and  any  of 
his  relatives  have,  and  a  tendency  to  bleeding  is 
suspected  in  the  case,  the  operator  should  ascertain 
whether  there  is  a  similarity  of  temperament  and 
constitutional  tendencies  between  the  patient  and 
such  relative. 

There  are  certain  conditions  in  which  excessive 
haemorrhage  would  be  more  likely  to  occur  than  in 
others  ;  as,  for  instance,  when  there  is  an  accidental 
relaxation,  or  deficient  tone  in  the  system,  especially 
the  vascular;  and  also  when  there  is  a  suppression 
of  any  periodical  discharges.  There  may  be  exces- 
sive haemorrhage  from  a  ruptured  vessel  when  there 
is  no  constitutional   haemorrhagic  tendency.     There 

sometimes  a  local  difficulty  with  the  vessels — a 
lack  of  tone  in  the  part — or  an  aneurismal  condition 
— on   account  of  which  obstinate   haemorrhage  will 


436  ACCIDENTS    IN   THE    EXTRACTION    OF   TEETH. 

occur.     A  peculiarity  of  this  kind  is  not  very  readily 
recognized. 

Violent  passion,  and,  indeed,  any  strong  agitation 
of  the  mind,  will  aggravate  haemorrhage.  Improper 
medication,  as  well  as  highly  stimulating  food,  will 
have  the  same  tendency.  Anything  that  will  in- 
crease the  circulation,  -or  reduce  the  tone  of  the 
vessels,  or  change  the  condition  of  the  hlood,  will 
increase  the  liability  to  haemorrhage.  Simple  deter- 
mination of  blood  to  a  part,  however,  would  not 
indicate  such  a  liability.  When  there  is  a  special 
haemorrhagic  diathesis,  the  blood  will  flow  from  all 
the  wounded  surface,  will  be  thrown  out  from  all  the 
ruptured  capillaries.  The  most  difficult  cases  are 
those  in  which  there  is  a  defect  both  in  the  vessels 
and  in  the  blood.  If  the  latter  is  in  a  good  condi- 
tion it  will  coagulate  in  ruptured  capillaries,  though 
they  might  be  deficient  in  tone ;  but  in  larger  vessels, 
though  coagulum  might  be  formed,  it  would  hardly 
be  retained. 

Treatment. 

In  cases  where  there  is  manifest  haemorrhagic  dia- 
thesis, prior  treatment  is  indicated,  if  the  necessity 
of  extraction  is  not  urgent;  and  that  treatment  will 
be  determined  by  the  peculiar  condition  of  the  case. 
If  there  is  a  lack  of  tone  in  the  vessels — an  inability 
to  contract — then  the  treatment  should  be  of  a  tonic 


HEMORRHAGE — TREATMENT.  437 

character;  and  if  the  blood  is  in  good  condition,  this 
is  the  only  treatment  necessary ;  but,  if  in  a  vitiated 
state,  other  treatment  will  be  demanded,  the  object 
of  which  is  to  produce  an  increase  of  red  corpuscles, 
albumen  and  fibrin.  It  is  always  better  to  postpone 
an  operation,  if  at  all  practicable,  till  such  treatment 
can  be  had  as  will  bring  the  system  to  the  best  possi- 
ble condition. 

Of  the  several  methods  of  arresting  haemorrhage, 
the  proper  one  in  a  given  case  will  be  determined  by 
the  circumstances.  Styptics  or  astringents  applied 
directly  to  the  ruptured  surface  will  often  be  found 
to  produce  coagulation  of  the  blood,  and  thus  stop  its 
flow  without  anything  else.  This  kind  of  remedy 
will  be  efficient  in  those  cases  in  which  the  applica- 
tion will  produce  contraction  of  the  bleeding  vessels, 
as  well  as  coagulation  of  the  blood.  Sometimes  this 
class  of  agents  will  fail  to  accomplish  the  object ;  in 
which  case,  in  addition  to  them,  compression  should 
be  made  upon  the  part.  Indeed,  in  many  cases,  the 
compress  will  effect  all  that  is  desired,  without  any 
other  application. 

There  are  several  methods  of  applying  the  com- 
press ;  but  the  one  best  adapted  to  any  given  case 
will  be  determined  by  circumstances — such  as  the 
extent  of  the  wound,  the  character  of  the  haemor- 
rhage, the  location  of  the  injury,  and  the  size  of  the 
mouth. 


438  ACCIDENTS   TN   THE   EXTRACTION   OF  TEETH. 

A  very  common  method  of  making  compression  in 
the  socket  from  which  a  tooth  has  been  drawn,  is  to 
force  into  the  cavity  pledgets  of  cotton,  or  small 
strips  of  linen,  tightly  till  it  is  full.  It  is  well  to 
saturate  these  with  a  solution  of  tannin,  or  some 
astringent  preparation,  applying  it,  too,  in  connection 
with  the  compress.  In  some  cases,  a  simple  packing 
of  the  cavity  in  this  manner  is  quite  sufficient,  but 
in  others  it  is  necessary  to  retain  the  pledgets  in  the 
socket  by  means  of  further  compression.  This  is 
effected  by  placing  a  roll  of  linen,  or  perhaps  bet- 
ter, a  properly  formed  piece  of  cork,  on  the  packing, 
and  then  closing  the  jaws  tightly  upon  this,  and,  if 
need  be,  placing  a  bandage  under  the  chin,  and  tying 
it  firmly  over  the  head.  The  length  of  time  during 
which  it  will  be  necessary  to  keep  the  jaws  thus 
together  will,  depending  on  the  nature  of  the  case, 
be  from  one  to  six  hours.  After  the  haemorrhage  has 
entirely  ceased,  the  bandage  is  to  be  removed  care- 
fully, and  the  patient  instructed  to  hold  the  jaws 
together  on  the  compress  for  a  time  and  then  gradu- 
ally to  open  the  mouth,  and  remove  the  cork  with 
much  caution.  After  this  the  packing  should  re- 
main in  the  socket  from  one  to  three  days,  and  then 
be  removed  very  carefully,  one  piece  at  a  time,  lest 
the  ruptured  vessels  be  opened  and  the  haemorrhage 
caused  to  recur. 

The  object  in  applying  a  compress  is  to  bring  it  to 


HEMORRHAGE — TREATMENT.  439 

bear  upon  the  aperture  of  the  wounded  vessel,  and  in 
this  way  to  prevent  the  escape  of  blood,  till  coagulum 
is  formed  and  the  opening  permanently  closed.  The 
operator  should  ascertain  the  precise  point  from  which 
the  blood  flows,  and  form  the  compress  so  as  to  bear 
directly  upon  it.  If  the  flow  is  from  all  the  wounded 
surface,  then  the  compress  must  be  made  to  conform 
exactly  to  that  throughout. 

Another  method  of  making  the  compression,  is  to 
force  softened  wax  into  the  socket,  so  as  to  fit  it  per- 
fectly ;  remove  it  and  chill  it  in  cold  water ;  and  then 
introduce  and  make  compression  upon  it  in  the  man- 
ner already  described,  following  throughout  the  gen- 
eral directions.  Another,  and  probably  better,  me- 
thod is  to  form  cones  of  wax  cloth,  as  near  the  shape 
and  size  of  the  root  removed  from  the  socket  as  pos- 
sible. This  material  is  prepared  by  dipping  thin 
linen  into  melted  beeswax,  withdrawing  it  and  let- 
ting it  cool,  and  then  cutting  off  strips  of  from  a 
fourth  to  half  an  inch  wide,  and  rolling  them  to  the 
proper  size  and  shape  ;  having  softened  this  material 
by  heat  and  freed  the  socket  of  coagulum,  introduce 
and  press  it  firmly  into  place,  making  the  compression 
on  it  as  already  directed.  This  makes  a  very  efficient 
compress  for  many  cases. 

Plaster  of  Paris  is  sometimes  used  on  the  principle 
of  a  compress.  Having  the  plaster  mixed  of  the 
proper   consistence,  and   the   cavity   clear,  fill   com- 


440         ACCIDENTS    IX   THE    EXTRACTION   OF  TEETH. 

pletely  with  it,  let  it  set,  and  then  make  compression 
on  it  in  the  usual  manner. 

The  root  of  the  tooth  is  sometimes  returned  to  the 
socket,  to  serve  as  a  compress.  It  possesses  the  ad- 
vantage of  having  a  perfect  adaptation.  This  me- 
thod of  compression  may  be  made  more  thorough 
by  immersing  the  root  in  melted  wax,  and  then,  he- 
fore  this  becomes  too  hard,  introduce  it  into  its  orig- 
inal position.  This  makes  a  very  perfect  and  effi- 
cient compress.  If  the  crown  is  still  remaining,  when 
the  jaws  are  closed  it  will  come  in  contact  with  the 
opposing  teeth,  and  thus  be  kept  firmly  in  place,  with- 
out anything  further.  It  may  be  removed  carefully 
after  from  one  to  three  days.  In  cases  where  there 
is  haemorrhage  from  the  entire  wounded  surface,  there 
will  be  a  considerable  flow  of  blood  from  the  margin 
of  the  gum,  even  after  plugging  up  the  socket,  and 
making  compression  by  either  of  the  methods  de- 
scribed. In  such  case,  after  the  socket  is  plugged  up 
as  already  described,  a  plate  is  so  formed  as  to  fit 
tightly  over  the  gum,  and  draw  its  margin  down 
closely  upon  the  compress.  This  pressure  on  the 
bleeding  edges  of  the  gum  checks  the  flow  of  blood 
there.  The  plate  must  be  held  down  by  the  means 
already  described.  It  is  sometimes  difficult  to  obtain 
an  accurate  fit  for  the  plate,  so  as  entirely  to  pre- 
vent the  blood  from  continuing  to  ooze  out.  In  such 
cases,  make  the  plate  to  conform  as  nearly  as   con- 


HEMORRHAGE — TREATMENT.  441 

venient  to  the  part ;  then  fill  up  its  concavity  with 
plaster  of  Paris,  mixed  to  a  proper  consistence,  and 
then  place  the  whole  upon  the  part,  till  the  plaster 
conforms  exactly  to  it,  and  retain  it  there  till  the 
plaster  sets.  This  is  then  used  for  the  compress.  Or 
the  inside  of  the  plate  may  be  thickly  coated  with 
softened  .gutta-percha,  instead  of  plaster,  and  pressed 
upon  the  part  in  the  manner  already  described,  and 
employed  in  the  same  way. 

It  will  often  require  considerable  discrimination  to 
determine  the  best  method  of  obtaining  compression. 
Great  difficulty  is  occasionally  experienced  when  a 
portion  of  the  process  has  been  broken  away,  or  the 
soft  parts  have  been  lacerated. 

Various  preparations  are  used  as  hcemostatics. 
These  agents  serve  to  check  haemorrhage  in  two 
ways  :  first,  by  facilitating  coagulation  of  the  blood; 
and  secondly,  by  producing  a  contraction  of  the  ori- 
fice of  the  ruptured  vessels.  It  is  proper,  in  all  cases, 
to  use  styptics  in  connection  with  the  compress. 
The  following  agents  have  been  used  as  styptics  : 
tannic  acid,  creosote,  nitrate  of  silver,  chloride  of 
zinc,  sulphate  of  zinc,  oil  of  turpentine,  muriate 
of  iron.  The  methods  of  applying  these  different 
preparations  are  the  same.  The  agent  is  simply 
to  be  retained  in  contact  with  the  part  till  it  has 
exerted  its  influence.  A  solution  of  tannin  in  alco- 
hol, with  creosote,  «'<|iial  parts,  makes  a  very  power- 


442  ACCIDENTS    IN    THE    EXTRACTION   OF   TEETH. 

ful  styptic;  or  tannin  and  creosote  alone  is  perhaps 
equally  efficient. 

The  actual  cautery  is  sometimes  used  to  arrest 
haemorrhage,  but  the  propriety  of  using  it  in  cases 
where  there  is  a  manifest  haemorrhagic  diathesis  is 
exceedingly  doubtful.  When  the  cauterized  surface 
s  loughed  off,  the  haemorrhage  is  liable  to  recur  with 
increased  vigor,  indeed,  is  certain  to  do  so  in  almost 
every  case  where  there  is  a  strong  predisposition. 
Constitutional  treatment  may  be  employed  to  antici- 
pate haemorrhage;  and  it  should  have  in  view  an 
increase  of  the  relative  amount  of  red  corpuscles, 
albumen,  and  fibrin  in  the  blood,  and  also  the  pro- 
duction of  a  normal  tone  of  the  system.  Saline  pur- 
gatives may  be  used  with  very  decided  advantage, 
followed  by  acetate  of  lead  in  connection  with  opium, 
the  effect  of  the  lead  being  to  increase  the  coagula- 
bility of  the  albumen  and  fibrin.  Care  should  be  ex- 
ercised, however,  in  its  administration. 

Excessive  haemorrhage  will  sometimes  occur  from 
very  slight  wounds ;  death  has  been  known  to  ensue 
from  simply  scarifying  the  gums. 

Mr.  C.  desired  the  removal  of  the  first  superior 
molar.  The  gum  was  separated  from  the  neck  of  the 
tooth  with  the  lancet,  in  the  usual  manner,  when  he 
refused  to  have  anything  further  done,  and  left  the 
office,  there  being  a  slight  discharge  of  blood  from 
the  gum.     After  a  few  hours  the  haemorrhage  in- 


HEMORRHAGE — TREATMENT.  443 

creased  so  as  to  cause  alarm  to  his  friends.  The 
patient  was  about  eight  miles  from  a  dentist,  and  a 
physician  of  rather  moderate  skill  was  called  to  the 
case.  He  probably  acted  according  to  his  best 
knowledge,  but  failed  to  arrest  the  haemorrhage,  and 
succeeded  in  convincing  the  friends  that  no  one  else 
could  do  better.  The  flow  of  blood  continued  three 
to  four  days,  proving  wellnigh  fatal,  but  at  last 
abated,  and  the  patient  recovered.  In  this  case,  a 
properly-directed  compress  would  have  checked  the 
bleeding  in  a  few  minutes. 

Another  case:  Mrs.  T.  had  nine  teeth  removed. 
The  operation  was  not  followed  immediately  by  un- 
usual haemorrhage,  but  within  two  or  three  hours 
the  flow  of  blood  had  increased  to  an  alarming  ex- 
tent, so  as  to  run  from  the  mouth  in  a  continuous 
stream.  The  indications  were  that  the  patient  would 
soon  die.  She  had  become  very  weak.  On  examina- 
tion, the  blood  was  found  issuing  only  from  the  socket 
of  one  root  of  an  inferior  molar.  The  mouth  and 
socket  being  cleansed  of  blood  and  coagulum,  it  was 
perceived  that  the  haemorrhage  was  from  a  small  ar- 
tery at  the  bottom  of  the  socket,  spouting  out  in  jets 
with  the  pulsations.  The  treatment  consisted  in 
rolling  up  pledgets  of  cotton  very  tightly,  saturating 
them  with  creosote  and  tannin,  and  forcing  them  in 
on  the  bottom  of  the  socket,  so  as  to  make  compres- 
sion upon  the  bleeding  vessel.     The  socket  was  then. 


444  ACCIDENTS    r\   THE   EXTRACTION    OF   TEETH. 

filled,  compression  made,  and  the  head  bandaged  in 
the  manner  already  described.  Thus  the  lisemor- 
rhage  was  immediately  checked  and  did  not  return. 
This  patient  was  of  a  scorbutic  diathesis. 

Excessive  bleeding  often  does  not  occur  till  a  con- 
siderable time  after  an  operation,  and  it  may  come 
on  without  any  exciting  cause,  or  be  induced  by 
vigorous  muscular  exercise,  or  by  any  intense  men- 
tal excitement.  Everything  of  this  kind  should  be 
avoided  where  there  is  a  predisposition  to  ha3mor- 
rhage,  and  everything  invited  that  would  tend  to 
maintain  the  equilibrium  of  the  circulation  and  the 
utmost  quiet. 

Fracture  of  the  Alveolus. 

The  ordinary  fracture  of  the  alveolus  is  a  matter 
of  no  considerable  consequence,  if  it  receives  proper 
attention.  This  fracture  occurs  to  a  greater  or  less 
extent  under  the  following  circumstances  : 

First.  When  there  is  great  divergence  of  the  roots, 
so  that  the  tooth  cannot  pass  from  its  socket,  unless 
one  or  more  of  them  are  broken  off,  or  the  alveolus  is 
fractured. 

Second.  Where  the  tooth  is  forced  out  of  the 
socket  at  a  very  considerable  angle  with  its  axis. 

Third.  Where  the  alveolus  is  very  firmly  attached 
to  the  roots,  and  is  very  thin  toward  the  point  of 
these. 


FRACTURE    OF   THE   ALVEOLUS.  445 

Usually,  the  fracture  is  of  that  part  which  forms 
the  socket  of  the  tooth  removed ;  and  when  this  is 
the  case,  it  is  of  but  small  moment.  It  sometimes, 
however,  extends  far  beyond  this,  involving  the  al- 
veolus of  from  one  to  four  of  the  adjacent  teeth,  and 
causing  very  serious  injury,  even  the  loss  of  the  teeth 
themselves.  Extensive  fracture,  however,  is  far  less 
liable  to  occur  now  than  when  less  perfect  instruments 
were  employed.  When  the  key  was  in  general  use, 
extensive  fracture  of  the  alveolus  was  frequent ;  but 
with  the  forceps,  it  is  comparatively  rare. 

When  an  accident  of  this  kind  does  occur,  all  of 
the  detached  portion,  whether  large  or  small,  should 
be  removed.  A  pair  of  bone  nippers,  or  enucleating 
forceps,  will  answer  for  this  purpose.  If  there  is 
much  attachment  of  the  soft  parts,  it  should  be  dis- 
sected off,  and  then  removed.  If  such  fractured  por- 
tions are  permitted  to  remain,  inflammation,  and 
oftentimes  sloughing  of  the  gums,  will  ensue ;  necro- 
sis of  the  bone  is  also  sometimes  produced  by  detached 
bone  remaining  in  contact  with  the  living. 

nnetimes  extensive  fracture  occurs,  involving  the 
adjacent  bony  structure.  In  the  case  of  Mr.  W.,  in 
an  effort  to  remove  the  first  superior  molar,  the  outer 
wall  of  the  alveolus  was  separated  from  the  other 
teeth.  The  fracture  extended  almost  to  the  zygo- 
matic process,  and  detached  a  portion  of  the  floor  of 
the  antrum,  as  well  as  a  part  of  its  outer  wall.    After 


146  ACCIDENTS    IN    THE    EXTRACTION    OF    TEETH. 

the  removal  of  this  detached  portion,  there  was  a  con- 
siderable external  depression,  thai  very  much  marred 
the  form  and  symmetry  of  the  face. 

Fracture  of  the  alveolus  should  always  be  guarded 
againsi  as  carefully  as  possible.  It  always  makes  an 
unfavorable  impression  on  the  mind  of  the  patient, 
which  in  many  eases  no  explanation  can  obliterate. 
Whenever  the  accident  does  occur,  the  disagreeable 
knowledge  of  it  may,  if  practicable,  remain  a  secret 
with  the  operator. 

Laceration  of  the  Gums. 

The  sums  are  often  bruised  and  lacerated  with  the 
key  in  the  extraction  of  teeth.  But  this  accident 
seldom  happens  with  the  forceps;  indeed,  never,  un- 
less the  gum  is  very  firmly  attached  to  the  neck  of 
the  tooth,  and  has  not  been  separated  with  the  lan- 
cet. The  gum  will  sometimes  be  lacerated  by  adher- 
ing to  a  piece  of  the  process  while  the  tooth  is  drawn 
from  its  socket,  with  the  process  and  gum  attached. 
With  the  various  hooks  and  punches,  the  gums,  lips, 
and  cheeks  are  sometimes  wounded.  Accidents  of 
this  kind  are  to  be  prevented  by  placing  a  finger  of 
the  left  harid,  or  a  guard  made  of  a  roll  of  linen,  in 
front  of  the  instrument.  When  any  considerable 
portion  of  gum  is  lacerated,  the  detached  portion 
should  be  cut  off'.     The  worst  consequences  from  lace- 


BREAKING   THE   TEETH.  447 

ration  of  the  soft  parts  occur  where  there  is  a  hemor- 
rhagic diathesis.  The  most  effectual  means  of  pre- 
venting accidents  of  this  kind  is  to  separate  the  gum 
perfectly,  and  guard  well  the  points  of  the  instrument. 

Breaking  the  Teeth. 

This  is  an  accident  of  no  small  consequence,  and  is 
liable  frequently  to  occur  in  the  use  of  imperfect,  ill- 
adapted  instruments,  or  in  the  unskilful  use  of  good 
ones.  •  It  is  of  very  common  occurrence  when  the  key 
is  employed  for  extracting,  even  in  the  hands  of  those 
who  claim  to  be  skilled  in  its  use.  And  with  forceps, 
too,  of  the  primitive  form,  the  teeth  were  so  frequently 
broken,  as  almost  to  preclude  their  use  as  extracting 
instruments.  This  accident  usually  occasions  great 
pain  to  the  patient,  as  well  as  protracts  the  operation, 
and  diminishes  his  confidence  in  the  ability  of  the 
operator.  One  such  accident  will  create  more  preju- 
dice than  many  skilful  operations  can  obliterate. 

In  all  cases  where  a  tooth  is  broken,  the  root,  if 
possible,  should  be.  removed :  for  if  it  be  not,  con- 
tinuous or  periodical  pain,  inflammation,  alveolar  ab- 
38,  and  like  affections,  are  liable  to  ensue.  The 
remark  is  often  made,  when  teeth  are  broken,  that 
the  gums  will  close  over  the  roots,  and  thus  effect- 
ually  protect  them,  and  no  disagreeable  consequences 
will  follow.     In  ii<>  ordinary  case  will  the  gums  unite 


448  ACCIDENTS    IN    THE    EXTRACTION   OF   TEETH. 

over  even  the  smallest  portion  of  root  that  may  have 
been  left  in  the  socket. 


Removal  of  a  Wrong  Tooth. 

There  is  very  rarely  any  excuse  for  the  removal  of 
a  sound,  healthy  tooth  in  the  immediate  vicinity  of  a 
diseased  one,  unless  it  be  in  a  case  of  those  deepseated, 
hidden  affections  which  are  difficult  to  diagnose.  It 
sometimes  happens,  however,  that  a  sound  tooth  is 
removed ;  and  when  a  mistake  of  this  kind  is  made, 
the  diseased  tooth  should  also  be  at  once  removed, 
and  then,  if  the  conditions  are  favorable,  the  healthy 
one  should  be  immediately  replaced.  The  circum- 
stances most  favorable  for  such  replacement  are  a 
good  constitution  in  a  state  of  health,  and  a  normal 
condition  of  the  mouth,  especially  of  the  gums  and 
mucous  membrane,  so  that  the  attachment  would  take 
place  with  as  little  inflammation  and  soreness  as 
possible.  If  the  tooth  is  necessarily  kept  out  of  the 
mouth  many  minutes,  it  should  be  placed  in  water  at 
about  blood  heat;  and  before  the  replacement,  the 
socket  should  be  thoroughly  cleansed  of  coagulum. 
The  tooth  is  then  introduced,  pressed  firmly  to  place, 
and  allowed  to  remain,  without  disturbance  or  irrita- 
tion, till  the  attachment  has  become  complete.  Dur- 
ing the  time  it  is  reuniting,  treatment  may  be  required 
to  counteract  inflammation.     Meagre  diet,  abstinence 


REMOVAL   OF   A   WRONG  TOOTH.  449 

from  stimulants,  and  quiet,  should  always  be  recom- 
mended in  the  case. 

This  operation  has  been  wholly  condemned  by  some 
very  good  dentists.  Dr.  Koecker  declares  that  it 
should  never  be  attempted.  But  numerous  success- 
ful cases,  well  attested,  give  assurance  that  it  may 
very  frequently  be  accomplished  with  the  most  satis- 
factory results.  Mr.  T.,  aged  fifteen  years,  of  good 
constitution,  and  in  good  health,  and  with  the  mouth 
principally  in  a  normal  condition,  had  the  second 
inferior  bicuspid  of  the  left  side  removed  by  mistake,, 
the  first  molar  being  the  offending  tooth.  The  former 
was  at  once  put  into  cold  water,  and  the  latter  forth- 
with extracted.  The  socket  of  the  biscuspid  was  then, 
cleansed,  and  the  tooth  replaced.  There  was  slight 
Boreness  for  a  few  days,  after  which  the  tooth  was 
found  to  have  made  a  firm  and  permanent  re-attach- 
ment, and  from  that  time  to  this — thirty-eight  years 
— it  has  remained  perfect,  and  is  now  as  healthy,  life- 
like, and  valuable  as  any  other  tooth  in  the  mouth. 

Since  the  issue  of  the  first  edition  of  this  work, 
many  cases  have  come  under  the  observation  of  the 
writer  in  which  detached  teeth  have  been  replaced, 
ami  become  as  firmly  fixed  in  the  socket  as  before  re- 
moval, and  remained  in  apparently  a  healthy  condi- 
tion so  liir  as  the  attachment  is  concerned.  In  some 
of  these  cases  very  unfavorable  conditions  were 
present. 

29 


450  ACCIDENTS   IN"   THE   EXTRACTION   OF   TEETFI. 

So  numerous  and  successful  have  these  cases  been, 
that  the  feasibility  of  replacing  teeth  that  have  been 
removed  is  a  matter  no  longer  to  be  controverted,  and 
especially  when  favorable  conditions  exist — good 
health  and  tone,  both  general  and  local,  and  the  parts 
involved  not  too  much  fractured  or  lacerated. 

Dislocation"  of  the  Inferior  Maxilla. 

The  dislocation  of  the  inferior  maxilla  is  an  acci- 
dent of  not  very  frequent  occurrence.  In  persons  of 
lax  muscles  and  with  large  mouths,  the  operation  of 
extracting  teeth  is  liable  to  produce  it — sometimes 
when  the  operation  is  on  the  upper  jaw,  but  more 
frequently  when  it  is  on  the  lower.  In  the  former 
case,  it  is  a  result  of  the  patient's  effort  to  open  the 
mouth  ;  but  in  the  latter,  generally  that  of  the  move- 
ment of  the  jaw  by  the  instrument.  The  dislocation 
consists  in  a  downward  and  forward  movement  of 
one  or  both  of  the  condyles,  so  that  they  are  thrown 
out  of  their  sockets,  and  rest  in  front  of  the  anterior 
rim.  In  such  case,  the  mouth  is  distended  to  its  ut- 
most, the  chin  thrown  down  on  the  breast,  and  deg- 
lutition and  speech  rendered  impossible.  Sometimes 
but  one  condyle  will  be  thrown  out,  in  which  case 
the  jaw  is  thrown  downward  and  to  one  side. 

This  accident  seldom  or  never  occurs  with  patients 
who  have  small  mouths  or  firm  muscles.     When  it 


DISLOCATION    OF   THE   INFERIOR   MAXILLA.  451 

does   happen,    however,    the   dislocation    should    be 
promptly  reduced.     Of  the  various  methods  of  accom- 
plishing this  reduction,  the  one  most  commonly  em- 
ployed, which  is  very  efficient,  is  as  follows :  If  both 
condyles  are   dislocated,  place  corks  or  some  similar 
substance  between   the  superior  and  inferior  molar 
teeth  of  both  sides,   and   then,  with   the  fingers   of 
both  hands,  make  firm,  steady  pressure  on  the  chin 
upward   and    backward,  thus    forcing   the   condyles 
downward   and    backward    into    their  proper    place. 
If  but  one  condyle   is  out,  the  cork  should  be   ap- 
plied only  on   that  side,  and   in  the   manner  already 
directed.       Another   method    is,    to    substitute    the 
thumbs  of  the  operator  for  the  corks,  placing  them 
in  the  same  position  between  the  teeth,  and  manipu- 
lating with  the  fingers  on  the  chin,  as  before.     The 
patient  should  be  placed  in  a  recumbent  position  for 
the   operation.     Another   method  is,  to  make  down- 
ward and  backward  pressure  on  the  coronoid  process, 
and  in  this  manner  cause  the  condyles  to  glide  into 
their  places.     This  accomplishes  the  reduction  with- 
out taking   hold   of  the  jaws,  or  placing  a  fulcrum 
between  them. 

This  accident  is  far  more  liable  to  occur  the  second 
time  in  the  sum-  ease  In  extracting  the  lower  molar 
teeth  for  a  person  who  has  suffered  a  dislocation,  or 
is  predisposed  to  it,  the  lower  jaw  should  be  very 
firmly  supported  with  the  left  hand;  or  the  accident 


452  ACCIDENTS    IN    THE    EXTRACTION   <  »F   TEETH. 

may  be  prevented  by  placing  a  bandage  under  the 
chin  and  over  the  head,  so  that  the  month  cannot  be 
opened  to  its  furthest  extent;  and  this  is  the  surest 
method.  In  all  cases  after  an  accident  of  this  kind, 
the  patient  should  abstain  from  solid  food  for  a  few 
days,  or  at  least  till  the  soreness  is  abated,  and  avoid 
everything  promotive  of  inflammation. 

Syncope. 

Syncope,  or  fainting,  is  frequently  brought  on  by 
extraction  of  the  teeth,  and  even  by  other  operations 
upon  them;,  indeed,  it  is  sometimes  produced  simply 
by  cutting  the  gums,  or  by  the  sight  of  blood,  or,  in 
some  instances,  by  dread  of  an  operation.  It  con- 
sists in  an  intermission  of  the  heart's  action,  and 
consequent  irregularity  of  the  circulation,  accom- 
panied with  a  temporary  suspension  of  the  functions 
of  the  brain,  and  a  loss  of  consciousness.  Difficult 
or  suspended  respiration,  pallor  of  the  skin,  and  ina- 
bility to  move,  are  the  external  indications  of  the 
condition.  There  are  no  constitutional  appearances 
known  by  which  a  predisposition  to  syncope  can  be 
determined.  Persons  of  all  apparent  conditions  and 
peculiarities  are  subject  to  it.  The  most  strong,  ro- 
bust, and  healthy  sometimes  faint  under  the  most 
trivial  iniiuences,  while  others,  of  the  weakest  and 
feeblest  constitutions,  cannot  be   brought  into   this 


SYNCOPE.  453 

condition  by  any  ordinary  means ;  so  that  nothing 
can  be  predicated  of  appearances  as  to  such  predis- 
position. The  fainting  may  occur  once  or  twice  in 
the  same  case,  even  under  the  most  simple  operation, 
owing  to  some  temporary  condition  of  the  system, 
and  never  happen  again  under  any  circumstances 
whatever. 

It  sometimes  comes  on  before,  sometimes  after,  and 
sometimes  during  the  operation.  There  is  greater 
liability  to  it  after  a  recent  meal  than  after  digestion 
is  completed,  since  the  nervous  energy  during  diges- 
tion is  directed  to  the  stomach  and  its  appendages, 
and  thus  the  circulatory  apparatus  has  less  of  nervous 
force. 

The  frequent  occurrence  of  syncope  indicates  a 
constitutional  predisposition  to  it,  and  may  enable 
the  operator  to  anticipate  it  to  some  extent,  by  the 
aid  of  stimulants,  such  as  brandy,  or,  what  is,  in 
some  respects,  preferable,  a  galvanic  current.  The 
patient  subject  to  such  affection  should  be  placed, 
for  an  operation,  as  nearly  as  practicable  in  a  recum- 
bent position, — especially  for  the  extraction  of  teeth, 
— and  his  mind  kept  as  tranquil  as  possible. 

To  restore  the  patient  from  syncope,  place  him  in 
a  horizontal  position,  the  head  quite  as  low  as  the 
body,  and  apply  volatile  stimulants  to  the  nostrils, 
and  dash  water  on  the  face  and  chest.  All  compres- 
sion   should    be   removed  from   the  body,  especially 


\.~>\  ACCIDENTS    IN    THE    EXTRACTION    OF    TEETH. 

from  the  chest,  as  it  would  constrain  the  action  of 
the  respiratory  muscles.  This  remark  is  peculiarly 
applicable  to  female  patients.  This  treatment  will 
usually  be  quite  sufficient  to  effecl  a  rapid  reaction 
and  resuscitation. 


CHAPTER  XIII. 

anesthetics. 
Ether — Chloroform — Nitrous  Oxide. 

Sulphuric  Ether  was  the  first  agent  successfully 
employed  for  producing  insensibility  to  pain  during 
surgical  operations.  It  was  brought  to  the  notice  of 
the  profession  in  1846,  by  the  late  Dr.  Horace  Wells, 
of  Hartford,  Conn. 

The  mode  of  administering  it  is  by  inhalation  of 
the  vapor,  and  it  produces  its  effects  in  a  short  time, 
depending  on  the  quality  of  the  ether,  the  amount  of 
air  introduced  with  it,  and  the  susceptibility  of  the 
patient.  A  complicated  instrument,  denominated  an 
inhaler,  was  first  employed  for  its  administration, 
but  it  soon  became  apparent  that  this  was  not  at  all 
necessary,  and  that  simpler  methods  were  preferable, 
because  more  easily  regulated  and  adapted  to  vary- 
ing circumstances.  The  best  method  is  to  inhale  it 
from  a  sponge  or  napkin,  since  in  this  way  the  ad- 
mission of  the  air  can  be  controlled  entirely  by  the 
will  of  the  operator,  graduating  it  to  the  require- 
ments of  the  c;i 

During  the  administration,  the  patient  should  be 
in  a  reclining  posture,  though  it  is  held,  by  good  au- 


456  AX.Ks-rirKTics. 

thority,  that  a  horizontal  position  is  the  safest,  be- 
cause in  that  the  force  of  the  circulation  is  most 
nearly  equalized.  In  the  administration  of  general 
anaesthetics  the  circulation  is  always  more  or  less  af- 
fected. It  is  an  opinion  very  generally  received,  and 
probably  correct,  that  where  there  is  functional  de- 
rangement of  the  heart,  lungs,  or  brain,  general  an- 
aesthesia should  not  be  employed.  This  opinion, 
however,  is,  perhaps,  derived  more  from  analogy  than 
from  actual  observation.  It  is  true  that,  other  things 
being  equal,  the  liability  to  injury  in  such  case  would 
be  greater,  but  the  danger  with  both  ether  and  chlo- 
roform is,  that  there  are  cases  in  which  there  is  an 
undefinable  and  undetectable  idiosyncrasy,  or  mal- 
susceptibility  to  its  influence,  to  a  great  extent  inde- 
pendent of  pathological  conditions. 

The  patient  having  been  placed  in  a  comfortable 
position,  and  his  mind  freed  as  far  as  possible  from 
apprehension,  he  should  be  directed  to  breathe  tran- 
quilly by  full  inspirations,  carefully  guarding  against 
any  compression  of  the  chest,  so  as  to  allow  the  re- 
spiratory muscles  free  play.  During  the  administra- 
tion of  the  anaesthetic  a  strict  watch  must  be  main- 
tained over  the  patient,  having  reference  to  the  fol- 
lowing points:  The  breathing  should  be  free  and 
easy,  without  irritation  of  the  throat  or  bronchia  ;  the 
skin  should  not  become  blanched,  but  should  retain 
a  florid,  lively  color;  but   the  great  criterion  is  the 


ETHER CHLOROFORM.  457 

pulse,  and  the  indications  given  here  should  be  strict- 
ly observed  and  obejTed.  In  order  that  the  operator 
may  follow  every  indication,  he  should  be  familiar 
with  the  manifestations  of  the  pulse  in  different  con- 
stitutions and  under  different  circumstances.  During 
the  administration  of  ether  or  chloroform,  the  pulse 
usually  becomes  more  frequent ;  but  it  should  not  be 
much  accelerated,  nor  its  strength  and  fulness  be 
much  diminished.  Feeble  or  irregular  pulse  should 
in  all  cases  be  regarded  as  a  warning;  and  if  the 
feebleness  and  irregularity  be  very  marked,  the  ope- 
rator should  desist.  In  some  instances  death  has 
occurred  after  a  few  inhalations;  but  perhaps  only  in 
the  use  of  chloroform.  This  fact  indicates  that  the 
first  effects  of  the  administration  should  be  very  closely 
noted. 

The  degree  to  which  the  anaesthesia  should  be  car- 
ried is  a  matter  about  which  there  is  much  diversity 
of  opinion.  Every  condition  of  it,  from  that  of  sim- 
ple allayed  irritability  to  that  of  complete  insensibil- 
ity and  unconsciousness,  has  its  advocates.  But  the 
extent  to  which  the  administration  may  be  carried 
will  be  suggested  by  the  indications  already  referred 
to,  and,  if  these  are  unfavorable,  should  be  deter- 
mined at  once.  Mere  nausea,  however,  without  any 
other  unfavorable  symptom,  is  not  a  counter-indica- 
tion in  the  use  of  ether  or  chloroform. 

The  method   of  administering  chloroform   is  the 


458  ANESTHETICS. 

same  as  that  for  ether,  except  that  in  the  use  of  the 
former  more  care  and  closer  observation  are  required* 
Chloroform  is  more  rapid  and  powerful  in  its  action 
than  ether,  and  hence  more  liable  to  do  injury  ;  but, 
independently  of  this  fact,  it  is  generally  believed 
that  the  former  is  less  safe  than  the  latter,  when  taken 
into  the  system,  especially  by  inhalation.  A  mix- 
ture of  ether  and  chloroform,  or  chloric  ether — usu- 
ally equal  parts  of  chloroform  and  ether,  but  the  pro- 
portions are  sometimes  varied — is  used  by  some,  the 
object  being  to  secure  greater  promptness  than  with 
ether  alone,  and  incur  less  danger  than  with  chloro- 
form ;  and  it  is  probable  that  a  mutual  compensation 
in  these  respects  is  thus  to  be  attained. 

If  either  chloroform  or  ether  has  been  administered 
to  entire  unconsciousness,  the  patient  should  be  per- 
mitted to  pass  out  of  the  condition  spontaneously  ; 
for  after  such  a  revival  there  will  be  less  liability  to 
unpleasant  feelings,  as  headache,  depression,  and  nau- 
sea. The  fingers  of  the  person  administering  the 
chloroform  should  be  kept  on  the  carotid,  since  the 
state  of  the  circulation  will  be  better  recognized  by 
this  than  by  the  radial  artery,  and  it  is  a  more  con- 
venient point  for  observation.  In  favorable  cases,  it 
is  preferable  to  continue  the  inhalation  till  there  is 
muscular  relaxation. 

When  a  condition  arises  in  which  respiration  is 
suspended,  and  the  circulation  partially  or  altogether 


NITROUS   OXIDE.  459 

stopped — a  condition  of  imminent  peril — active  mea- 
sures must  be  resorted  to  for  the  patient's  restoration. 
Efforts  must  be  directed  to  a  recovery  of  the  circula- 
tion, by  friction,  motion,  etc. ;  but  to  restore  the  res- 
piration is  the  first,  immediate,  imperative  considera- 
tion. Any  or  all  of  the  ordinary  methods  of  re-estab- 
lishing suspended  respiration  may  be  employed.  Cold 
water  should  be  dashed  in  the  face,  and  on  the  throat 
and  chest,  and  volatile  stimulants  applied  to  the  nos- 
trils ;  the  glottis  should  be  titillated  with  a  feather, 
or  some  such  implement,  to  excite  it  to  action  ;  and 
artificial  respiration,  by  some  approved  method,  should 
be  at  once  adopted.  The  galvanic  current,  too,  may 
be  brought  into  requisition,  to  excite  the  respiratory 
muscles  to  action,  and  to  act  also  upon  the  circulation. 
In  all  cases  of  accident  of  this  kind,  prompt  and  effi- 
cient measures  should  be  immediately  taken,  for  a 
delay  of  a  few  moments  may  be  attended  with  fatal 
results. 

Nitrous  Oxide. 

Nitrous  oxide  is  now  used  as  a  general  anaesthetic 
quit*-  extensively  in  dental  practice.  This  agent, 
when  properly  prepared  and  judiciously  administered, 
is  perhaps  the  safest  general  anaesthetic  in  use;  it  is 
very  efficient  for  minor  surgical  operations,  and  we 
believe  it  will  ere  long  be  found  applicable  to  the  more 
protracted   and  graver  operations.     Its  efficiency  is 


460  ANAESTHETICS. 

very  much  modified  by  its  preparation  and  mode  of 
administration.  This  gas  when  pure  is  colorless,  and 
of  slightly  sweetish  taste  and  odor;  it  is  usually  pre- 
pared by  decomposition  of  nitrate  of  ammonia. 

It  is  not  the  purpose  bere  to  describe  tbe  method 
of  preparing  this  agent — that  has  been  well  done  by 
others ;  }^et  it  is  proper  to  suggest  here  that,  to  a 
large  extent,  tbe  knowledge  and  opinions  entertained 
on  this  subject  bave  been  very  circumscribed,  and  ex- 
ceedingly erroneous.  In  tbe  administration  of  nitrous 
oxide  as  an  anaesthetic,  great  care  sbould  be  exercised 
to  secure  the  best  results.  In  order  to  accomplish 
this,  it  should  be  inhaled,  and  in  no  case  but  once, 
diluted,  as  circumstances  may  indicate,  more  or  less 
with  pure  atmospheric  air ;  this  is  ordinarily  neces- 
sary only  at  the  beginning,  for  pure  nitrous  oxide  will 
sustain  respiration  for  an  indefinite  time. 

To  a  patient  in  an  anaesthetic  state,  it  is  not  so 
readily  administered  as  chloroform  or  ether;  but  the 
patient  under  its  influence  is  quite  as  manageable  as 
with  any  other  agent,  and  the  anaesthesia  as  perfect, 
but  not  as  prolonged  without  continued  administra- 
tion. 

It  is  scarcely  justifiable  in  ordinary  dental  practice 
to  use  a  more  heroic  general  anaesthetic  than  the  one 
here  referred  to. 

Nitrous  oxide  gas  is  now  prepared  in  liquid  form, 
and  may  be  procured  of  tbe  manufacturers,  ready  for 


NITROUS   OXIDE. 
Fig.  125. 


461 


use.  There  are  some  advantages  derivable  from  this. 
The  gas  in  this  form  is  prepared  l>y  persons  of  ex- 
tended  knowledge  and  experience  in  ehemieal  work, 


462  \\  r.-Tin.Th  -. 

which  gives  assurance  of  purity;  and,  in  addition  to 
this,  by  the  condensation  to  the  liquid  form,  any  ex- 
traneous gases  are  expelled,  and  thus  there  is  far 
greater  certainty  of  obtaining  pure  gas  than  when  it 
is  prepared  in  the  ordinary  way.  and  that  by  persona 
having  little  or  no  knowledge  of  chemical  science  or 
processes. 

The  accompanying  cut  (Fig.  L25)  represents  an 
ornamental,  convenient  and  efficient  gas-holder.  The 
liquid  gas  is  contained  in  the  cylinder  in  the  lower 
part :  from  this  the  gas  escapes  into  the  holder  ab 
directly  from  which  the  gas  is  administered  to  the 
patient.  A  portable  apparatus  lor  holding  and  ad- 
ministering the  gas  is  also  constructed,  which  for 
some  purposes  is  preferable  to  this. 

Local  Anaesthesia. 

Because  of  the  frequently  prejudicial  and  some- 
times fatal  consequences  to  which  systemic  anaesthe- 
sia is  liable,  local  anaesthesia  has  been  brought  into 
requisition  ;  the  first  method  of  accomplishing  this 
was  by 

Congelation. — Freezing  a  part,  to  produce  insensi- 
bility under  surgical  operations,  is  a  process  that  has 
long  been  in  use.  Various  methods  for  accomplishing 
it  have  been  employed.  There  are  perhaps  none  so 
well  adapted  to  the  dentist's  use  as  ether  spray.  So 
easy  of  application  is   it,  and  so  generally   efficient, 


LOCAL    ANAESTHESIA. 


463 


that  it  is  in  almost  universal  use.  To  Dr.  Richard- 
son, of  London,  is  due  the  credit  of  having  brought 
this  process  to  its  present  state  of  perfection. 

So  accurately   does   the   accompanying  engraving 
(Fig.  126)  represent  the  apparatus  used  in  this  pro- 


Fig.  126. 


cess,  that  a  minute  description  is  unnecessarv.  The 
mode  of  application  and  operation  is  apparent  at 
once. 

The  instrument  consists  of  the  fluid  holder — a 
four-ounce  bottle,  graduated — the  bellows  consisting 
of  a  rubber  ball,  with  the  proper  valves,  and  the 
points  from  which  proceed  the  spray,  and  these  all 
connected  by  the  proper-sized  flexible  tube. 

It  will  be  observed  that  there  are  variously-formed 
points,  Bingle  and  double,  straight  and  curved;  these 
are  required  for  the  various  processes  to  which  the 
instrument  is  applied. 

For   the  extraction  of  teeth,  the  double  point  is 


It",  \  ANAESTHETICS. 

applicable,  throwing  the  jet  upon  the  gum  each  side 
of  the  tooth  nt  the  same  time.  The  single  points 
are  required  where  an  incision  or  excision  is  to  be 
made. 

This  is  a  very  valuable  instrument,  and  is  exten- 
sively used  in  minor  surgical  operations,  and  is  espe- 
cially adapted  to  the  dentist's  use.  Ether  is  perhaps 
as  yet  the  best  agent  employed.  Rhigolene,  a  far 
more  volatile  fluid  than  ether,  has  been  used  to  a 
limited  extent,  but  owing  to  its  exceedingly  rapid 
evaporation,  its  action  is  too  violent,  and  not  so  easily 
controlled. 

For  inducing  local  anaesthesia,  various  prepara- 
tions have  been  suggested.  The  following  has  been 
in  use  for  several  years,  namely,  a  mixture  of  chloro- 
form, tincture  of  aconite,  belladonna,  and  opium. 

This  applied  to  the  gums,  or,  indeed,  to  any  other 
surface  tissue,  will  in  many  cases  very  much  obtund 
sensibility,  and  in  some  relieve  it  altogether,  so  that 
a  tooth  may  be  extracted,  or  a  deep  incision  made, 
without  pain. 

The  dental  pain-obtunder,  which  was  introduced  to 
the  profession  about  eight  years  ago,  for  relieving 
sensitive  dentine,  is  a  good  local  anaesthetic.  Another 
preparation,  made  and  introduced  by  Dr.  C.  Von  Bon- 
horst,  is  also  quite  efficient. 

Dr.  Von  B.  has  invented  an  instrument  for  using 
his  preparation,  or  any  other  for  like   purpose.     It 


EXTRACTION    BY    ELECTRO-MAGNETISM. 


465 


consists  of  two  small  metallic  cups,  attached  to  the 
ends  of  an  elongated  staple,  of  heavy  wire,  about 
seven  inches  long.  This  is  the  handle  of  the  appli- 
ance. 

The  sponges  are  placed  in  sections  of  rubber  tube, 
about  half  an  inch  in  length,  and  these  together  are 
placed  in  the  cups.  The  sponges  are  saturated  with 
the  anaesthetic  fluid  that  may  be  selected,  and  are 
applied  to  the  gum  on  each  side  of  the  tooth  to  be 
extracted,  and  retained  on  the  part  from  one-half  to 
two  minutes;  the  length  of  time  will  be  governed  by 
the  susceptibility  of  the  part,  the  agent  employed, 
and  the  extent  of  the  anassthesia  sought. 

Entire  insensibility  to  pain  cannot  thus  always  be 
obtained,  but  in  many  cases  it  can,  and  diminution 
of  it  in  all  cases  can  be  effected.  This  appliance  is 
very  convenient  for  the  purpose  for  which  it  is  used. 

The  following  cut  (Fig.  127)  represents  the  instru- 
ment ready  for  use. 

Fig.  127. 


Extraction  by  Electro-Magnetism. 


The  employment  of  electro-magnetism  in  the  ex- 
traction of  teeth  was   introduced  to  the  profession 

30 


466  ANAESTHETICS. 

about  twenty-five  years  ago,  and  at  one  time  was  ex- 
tensively used.  There  is  a  great  diversity  of  opinion 
as  to  its  efficienc}'  for  relieving  pain  ;  for,  while  some 
have  been  disposed  to  assume  that,  when  properly 
employed,  it  would  in  the  majority  of  cases  mitigate 
pain,  and  in  many  obviate  it  altogether,  others,  after 
having  thoroughly  tested  it,  as  they  affirm,  maintain 
that  it  does  not  produce  insensibility  to  any  appreci- 
able extent,  and  consequently  does  not  relieve  the 
pain,  but  that,  at  most,  it  only  complicates  the  sensa- 
tions, the  pain  of  the  tooth-drawing  becoming  in- 
volved in  the  confusion  of  other  feeling,  so  that  the 
patient  can  hardly  decide  whether  he  has  suffered 
pain  or  not. 

In  using  this  agent  for  the  purpose  of  extracting 
teeth,  the  susceptibility  of  the  patient  to  its  influence 
must  be  carefully  regarded.  Some  persons  are  so 
peculiarily  constituted  that  an  electric  current  is 
almost  intolerable  to  them,  while  others  will  receive 
a  strong  current  with  pleasurable  sensations.  To  the 
former,  the  electricity  would  be  as  painful  as  the  ex- 
traction of  the  tooth  ;  but  to  the  latter,  when  properly 
applied,  it  mitigates,  and  in  man}7  cases  altogether 
obviates,  the  pain.  The  reason  of  this  difference  in 
its  action  is  not  very  clearly  understood.  Several  the- 
ories in  regard  to  it  have  been  advanced,  but  none  of 
them  sufficiently  plausible  to  challenge  conviction. 

Again  the  manner  in  which,  and  the  condition  of 


APPLICATION.  467 

the  parts  to  which,  this  agent  is  applied,  are  to  be 
closely  observed.  Where  there  is  acute  periostitis,  an 
electric  current,  even  though  feeble,  would  produce 
intense  pain,  and  should  not  be  applied  ;  though  in 
such  cases  it  has  been  suggested  that  an  application 
of  the  charged  sponge  to  the  gums  will  produce  in- 
sensibility. 

Application. 

The  method  of  application  is  very  simple.  Any 
ordinary  batter}^  of  convenient  form,  may  be  em- 
ployed for  this  purpose.  It  should  be  uniform  in  its 
action,  and  the  vibration  as  short  as  possible.  The 
common  zinc-and-copper  battery,  with  the  sulphate- 
of-iron  solution,  is  perhaps  the  most  convenient  and 
safe.  One  pole  of  the  battery — no  matter  which — is 
attached  to  the  forceps,  and  the  other  to  a  handle  of 
size  and  form  convenient  for  the  patient  to  grasp.  To 
ascertain  his  susceptibility,  the  current  should  always 
first  be  tested  on  the  patient,  by  placing  the  handle 
and  the  forceps  one  in  each  of  his  hands,  and  letting 
it  on,  first  feebly,  and  then  gradually  increasing  it  till 
he  experiences  the  sensation  just  beyond  the  elbows; 
when,  finally,  it  is  to  be  slightly  weakened.  The 
gum  having  been  separated,  the  forceps,  with  its  ap- 
pendages, is  adjusted  to  the  tooth,  the  connection 
made  by  placing  the  handle  in  the  patient's  hand, 
and  the  tooth  at  that  moment  removed.    It  has  been 


468  ANAESTHETICS. 

recommended  by  some  to  place  the  forceps  on  the 
tooth,  and  complete  the  circuit  as  above,  with  the 
current  very  feeble,  and  then  gradually  increase  it 
to  the  proper  force  for  the  operation.  In  some  in- 
stances, perhaps,  this  would  be  the  preferable  mode. 
Another  method  of  producing  insensibility  by  an 
electric  current  is,  to  place  two  moistened  sponges* 
connected  with  the  two  poles  of  the  battery,  on  the 
gum,  one  on  each  side  of  the  tooth,  keep  them  there 
a  few  moments,  and  then  operate.  This  method, 
however,  has  not  yet  been  sufficiently  tested  to  ascer- 
tain its  merits. 


APPENDIX. 


In  the  following  pages  are  presented  a  few  subjects  more  at 
length  than  is  practicable  or  desirable  in  the  body  of  the  work. 

Section  A  consists  of  selections  from  "  Watt's  Chemical  Es- 
says "  on  "  Caries  of  the  Teeth." 

This  is,  perhaps,  the  most  accurate  and  concise  presentation  of 
that  subject  in  the  English  language.  In  treating  of  the  subject, 
it  deals  with  established  principles  and  with  facts,  and  discards 
all  mere  hypothesis,  which  has  commonly  entered  so  largely  into 
the  discussion  of  the  subject.  A  careful  and  thorough  study  of 
the  subject,  as  here  presented,  is  suggested.  T. 

SECTION  A.— DENTAL  CARIES. 

It  is  now  admitted,  by  all  who  are  familiar  with  the  subject, 
that  whatever  may  be  the  predisposing  causes,  the  immediate 
cause  of  dental  caries  is  chemical  action.  It  is  well  known  that 
constitutional  causes  have  much  to  do  with  this  disease,  both  in 
producing  badly-organized,  defective  teeth,  and  in  eliminating  or 
preparing  the  agents  which  act  chemically  on  them.  But  no  con- 
stitution produces  teeth  so  defective  that  they  undergo  sponta- 
neous decomposition  while  retaining  a  vital  connection  with  the 
general  system.  I  am  aware  that  a  few  pathologists  still  main- 
tain that  inflammation  of  the  bony  texture  of  the  teeth  is  liable 
to  the  same  terminations  as  inflammation  of  ordinary  bony  tissue, 
but  it  is  not  profitable  to  debate  this  point  in  the  present  paper. 
Suffice  it  to  say  that  the  structure  and  position  of  the  enamel 
indicate  that  the  danger  is  from  without,  not  from  within. 


470  APPENDIX. 

As  soon  as  it  is  admitted  that  decay  of  the  teeth  results  from 
chemical  action,  it  is  natural  to  inquire  what  agent  or  agents  pro- 
duce this  action.  Accordingly,  we  find  the  profession  turned  at 
once  in  this  direction.  And  when  the  composition  of  the  teeth  is 
taken  into  the  account,  we  would  infer  that  the  deleterious  agents 
are  to  be  looked  for  among  the  acids.  And  here  we  have  had 
great  confusion  of  ideas,  aud  are  still  likely  to  have  it.  For  ex- 
ample, we  are  told  "  that  it  is  proven  that  nearly  all  the  acids,  both 
mineral  and  vegetable,  act  readily  upon  the  teeth."  (Harris's 
Dictionary,  article  "  Caries  of  the  Teeth.")  Upon  any  part  of  the 
teeth  ?  Or,  are  we  to  understand  that  some  of  them  act  on  the 
animal  portion,  some  on  the  earthy,  and  some,  or  all,  on  the  en- 
amel ?  Just  turn  to  the  index  of  almost  any  chemical  textbook, 
and  ask  yourself  if  it  is  proved  that  nearly  all  of  the  acids  there 
named  act  readily  upon  the  teeth.  Do  carbonic  acid,  tannic  acid, 
and  scores  of  others  that  might  be  named,  act  readily  upon  the 
teeth?  This  expression,  and  many  others  that  might  be  quoted 
from  various  writers,  show  a  professional  longing  for,  rather  than 
an  attainment  of,  the  truth  in  regard  to  this  matter. 

Now,  for  convenience,  let  us  assume  that  dental  caries  is  pro- 
duced by  the  action  of  acids.  The  question  still  arises,  what 
acids?  Are  many  acids,  or  only  a  few,  concerned  in  its  produc- 
tion ?  One  of  the  laws  of  combination  teaches  us  that  chemical 
compounds  are  definite  in  their  nature.'  Chemical  action  is  always 
definite.  When  an  acid  combines  with  an  alkali,  or  base,  a  defi- 
nite compound,  called  a  salt,  is  formed.  When  a  different  acid 
unites  with  this  same  base,  a  different  salt  is  formed.  Each  salt, 
each  chemical  compound  of  any  kind,  is  distinguished  from  all 
others  by  characteristics  peculiar  to  itself.  It  is  unlike  all  other 
substances,  in  some  respects.  Each  chemical  result  differs  from 
all"  other  chemical  results.  Of  course,  then,  a  great  variety  of 
chemical  reagents  will  produce  a  great  variety  of  chemical  re- 
actions. 

Let  us  now  inquire  as  to  the  various  characteristics  of  those 
chemical  actions  which  result  in  what  we  recognize  as  dental 
caries.  Do  we  here  find  a  great  variety  of  appearances?  Or,  is 
it  not  well  known  that  the  phenomena  of  caries  are  so  few  and  so 
circumscribed  that,  by  common  professional  consent,  but  three  or 


DENTAL   CARIES.  471 

four  varieties  of  it  are  recognized  ?  We  find  one  variety  often 
called  "  white  decay,"  and  another  that  is  brownish  in  color,  and 
a  third  that  is  very  properly  designated  as  "  black  decay."  These 
differ  in  other  respects  as  well  as  in  color.  In  the  white  variety 
all  the  components  of  the  teeth  are  acted  on,  and  disintegrated, 
as  far  us  the  disease  extends.  In  the  second  variety,  the  earthy 
portion  of  the  teeth  seems  to  be  removed,  while  much  or  all  of 
the  animal  portion  remains,  which  is  conclusive  evidence  that 
the  chemical  agent,  whatever  it  may  be,  forms  soluble  compounds 
with  the  earthy  materials.  In  the  "  black  decay  "  there  is  less 
disintegration  of  the  tooth  substance  than  in  either  of  the  other 
varieties ;  and  it  progresses  less  rapidly  than  either  of  them.  The 
physical  characteristics  of  this  variety,  aside  from  the  chemical, 
would  indicate  that  the  chemical  agent  principally  concerned  in 
its  production  forms,  mainly,  insoluble  compounds  with  the  con- 
stituents of  the  tooth.  Then,  there  is  a  fourth  variety,  commonly 
called  "  chemical  abrasion,"  in  which  the  entire  tooth-substance 
is  removed,  as  far  as  the  disease  extends.  It  is  evident  that  the 
agent  producing  this  dissolves,  or  forms  soluble  compounds,  with 
both  the  animal  and  earthy  materials  of  the  tooth. 

Unless  we  conclude  that  chemical  compounds  are  not  definite 
in  their  nature,  and  that  many  reagents  may  produce  but  a  few 
reactions,  we  are  forced  to  the  conclusion  that  dental  caries,  as 
observed  and  recognized,  results  from  the  action  of  but  few  sub- 
stances on  the  teeth.  It  is  very  probable  that  each  distinct  variety 
is  produced  by  the  action  of  a  single  agent,  and  invariably  by  the 
same  agent.  I  am  well  aware  that  more  than  one  variety  may 
be  found  in  the  same  mouth  at  the  same  time,  and  in  close  prox- 
imity; and,  consequently,  any  given  case  of  caries  may  partake 
of  the  characteristics  of  more  than  one  variety.  It  is  not  uncom- 
mon to  find  "white  decay"  attacking  a  tooth  in  a  cavity  pri- 
marily affected  with  the  brown  or  colorless  variety.  But  every 
practitioner  is  familiar  with  unmixed  cases,  representing  all  the 
four  classes  specified. 

The  physical  characteristics  of  decay  depend  much  on  the  tex- 
ture of  the  teeth   affected,  but  they  are  dependent,  also,  on  the 
nature  of  the  compounds  formed   by  the  union  of  the  destroying 
at  with  the  constituents  of  the  teeth.     The  degree  of  conceu- 


472  AI'I'EN'DIX. 

tratiou  of  the  chemical  agent  has  also  a  modifying  influ 
"When  much  diluted,  its  action  is  almost  .solely  in  obedience  to  its 
Strongest  affinity.  For  example,  if  nitric  acid  were  the  agent, 
when  concentrated  it  would  act  energetically  on  the  animal  as 
well  as  on  the  earthy  materials  of  the  teeth,  but  when  much  di- 
luted its  ;i<-t inn  would  be  almost  confined  to  the  latter. 

The  chemical  characteristics  of  decay,  however,  depend  almost 
exclusively  on  the  character  of  the  agent  producing  it.  The  truth 
of  this  appears  evident  when  we  reflect  that  bad  teeth  and 
ones  are  composed  of  the  same  chemical  substances.  Marble  and 
chalk  are  alike  in  chemical  composition,  but  not,  in  physical  struc- 
ture, and  though  an  acid  acts  more  rapidly  on  the  latter  than  on 
the  former,  yet  the  result  of  the  actiou  is  the  same.  An  acid, 
too,  will  act  with  more  energy  on  a  soft,  porous  tooth  than  on 
one  of  firmer  texture,  yet  the  chemical  results  are  the  same.  It 
is  safe  to  conclude,  then,  that  as  there  are  but  few  results  in  the 
chemical  actions  attendant  on  dental  caries,  there  are  but  few 
chemical  agents  immediately  concerned  in  their  production. 

It  is  not  to  be  inferred  from  the  above  that  but  few  agents  are 
capable  of  injuring  the  teeth  by  chemical  action.  Many  acids 
used  in  food,  or  as  medicines,  are  capable  of  doing  injury  to  the 
teeth.  But  no  one  need  suppose  that  an  acid,  even  though  con- 
siderably concentrated,  brought  occasionally  in  contact  with  the 
teeth,  is  the  immediate  cause  of  caries.  Every  close  observer  will 
conclude  that  caries  is  the  result  of  an  agent  acting  slowly  and 
steadily  in  the  accomplishment  of  its  work.  He  will  be  apt  to 
infer  that  this  agent  is  either  formed  by  chemical  action  within 
the  mouth,  or  is  eliminated  therein,  either  as  a  secretion  or  an  ex- 
cretion, and  that  it  quietly  performs  its  disastrous  deeds  as  fast  as 
formed  or  eliminated.  The  application  to  the  teeth  of  an  acid 
capable  of  acting  chemically  on  them,  facilitates  or  predisposes 
to  the  production  of  caries,  and  this  it  may  do  without  this  acid 
being  the  immediate  cause  of  the  decay.  A  tooth  may  be  frac- 
tured, or  its  enamel  removed,  by  mechanical  means,  and,  as  the 
dentine  is  thus  exposed,  the  tooth  is  more  liable  to  caries  than 
before  the  exposure.  But  no  one  supposes  that  the  mechanical 
action  which  exposes  the  dentine  is  the  immediate  cause  of  the 
caries.     The  dentine  would  remain  sound  and  healthy  did  not 


DENTAL    CAEIES.  473 

some  chemical  agent  attack  it.  In  like  manner,  in  the  adminis- 
tration of  acids  as  food  or  medicine,  the  teeth  may  be  so  corroded 
as  to  expose  the  dentine  and  render  it  as  liable  to  the  action  of 
the  carious  agent  as  in  the  former  case ;  or,  if  the  dentine  is  not 
exposed,  the  enamel  may  be  roughened,  either  mechanically  or 
chemically,  so  as  to  afford  a  lodgment  for  organic  matter,  which, 
by  decomposition,  may  generate  one  of  the  acids  immediately 
concerned  in  the  production  of  caries.  On  this  principle,  acid 
medicines  and  acid  foods  may  indirectly,  but  not  immediately, 
cause  caries.  The  same  remarks  will  apply  to  acids  brought  in 
contact  with  the  teeth  by  eructation  or  vomiting. 

If  this  view  is  correct,  the  investigation  of  the  subject  of  dental 
caries  is  brought  within  a  narrower  compass  than  many  suppose. 
The  first  step  is  to  inquire  what  acids,  in  health  and  disease,  are 
liable  to  be  secreted  or  excreted,  so  as  to  be  brought  regularly  in 
contact  with  the  teeth.  The  second  is  to  ascertain  what  acids  are 
liable  to  be  formed  within  the  mouth  by  fermentation  or  otherwise. 
And  the  third  is  to  discover  what  ones  of  all  these  are  capable  of 
producing  the  phenomena  of  dental  caries.  There  is  but  little 
room  to  doubt  that,  at  least,  each  of  the  first  three  varieties  is  the 
result  of  a  specific  agent. 

To  properly  understand  any  chemical  action  to  which  the  teeth 
are  subject,  it  is  necessary  to  bear  in  mind  their  texture  and  com- 
position, and  to  consider  the  chemical  properties  of  at  least  their 
principal  constituents.  It  must  also  be  remembered  that  the  teeth 
are  endowed  with  vitality.  'As  dental  caries — the  most  common 
disease  of  the  human  race — is  now  universally  conceded  to  be  the 
result  of  chemical  action,  the  importance  of  this  subject  is  at  once 
manifest.  The  time  is  not  far  distant  when  in  every  case  of  recent 
caries,  the  enlightened  practitioner  will  be  able,  by  the  character 
of  the  decay  and  the  habits  and  constitution  of  the  patient,  to 
detect  and  identify  the  agent  or  agents  producing  the  disease. 
Any  practice  short  of  this  knowledge  must  be,  at  least  to  some 
extent  guesswork,  and  is,  although  the  best  we  can  now  do,  em- 
pi  rical  practice. 

The  fact  that  an  active  alkaline  base  is  the  principal  Inorganic 
ingredient  of  the  teeth,  would  indicate  clearly  that  their  great 
danger  lie-  in  the  presence  of  acids;  and  all   experience  demon- 


474  APPENDIX. 

strates  the  truth  of  this  inference.  This  danger  is  also  greater 
from  the  fact  that  the  principal  salt  of  this  base,  present  in  the 
tooth -substance,  combines  with  several  acids  without  undergoing 
decomposition. 

It  is  evident  that  the  acids  do  not  all  act  alike  on  the  teeth. 
Indeed,  some  exert  no  influence  whatever  on  them,  while  others 
act  with  great  energy  on  each  and  all  of  their  constituents.  It 
would  be  an  endless  task  to  consider  all  the  substances  which  are 
capable  of  exerting  an  injurious  chemical  influence  on  the  teeth  ; 
and  perhaps  it  would  be  as  unprofitable  as  endless.  All  that  is 
now  aimed  at  is  an  accurate  account  of  the  various  substances 
which  ordinarily  act  chemically  on  the  teeth — which  produce 
caries  and  "  chemical  abrasion." 

Without  further  preface,  we  will  proceed  to  notice  some  of  the 
chemical  agents  alluded  to. 

Nitric  Acid. — This  acid  is  composed  of  five  equivalents  of  oxy- 
gen united  with  one  of  nitrogen.  Its  symbol  is  therefore,  N06. 
It  acts  with  great  energy  on  all  the  constituents  of  the  tooth.  Its 
great  energy  of  action  depends  on  a  variety  of  circumstances.  As 
an  acid,  it  unites  energetically  with  bases,  and  will,  therefore,  take 
the  lime  and  kindred  bases  from  the  weaker  acids.  From  its  ready 
decomposition,  it  affords  oxygen,  in  its  nascent  condition,  for  the 
destruction  of  oxidizable  substances.  Its  action  on  the  tooth  may 
be  thus  briefly  described :  it  dissolves  the  phosphate  of  lime,  de- 
composes the  carbonate,  setting  the  carbonic  acid  free,  and  form- 
ing nitrate  of  lime,  and  destroys  the>  orgauic  portion,.,  producing 
a  highly-softened  state  of  the  carious  matter.  In  fact,  it  is  a 
prominent,  if  not  the  principal  agent  in  the  production  of  the 
"  white  decay." 

But  the  question  naturally  arises,  Is  an  agent  so  destructive  in 
its  tendencies  likely  to  come  in  contact  with  the  teeth,  and  if  so, 
under  what  circumstances  ?  The  question  is  important,  and  the 
answer,  perhaps,  difficult. 

It  is  well  known  that  this  acid  is  frequently  administered  as  a 
tonic ;  and  it  is  a  lamentable  fact  that  far  too  little  attention  is 
paid  to  the  prevention  of  its  injurious  effects  on  the  teeth  in  such 
cases,  but  this  will  by  no  means  account  for  the  frequency  with 
which  it  evidently  injures  the  dental  organs.  A  few  thoughts  in 
regard  to  its  formation  may  throw  some  light  on  the  subject. 


DENTAL   CARIES.  475 

It  is  a  singular  fact  that  though  nitrogen  and  oxygen  manifest 
but  little  affinity  for  each  other,  yet  they  unite  in  various  propor- 
tions, forming  at  least  five  well-known  distinct  compounds.  It 
appears,  however,  from  a  variety  of  circumstances,  that  their  ten- 
dency is  to  unite  in  the  proportions  which  form  nitric  acid.  The 
protoxide  is  readily  decomposed,  and  yields  nitrogen,  oxygen,  and 
nitrous  acid.  The  binoxide,  if  brought  in  contact  with  the  atmos- 
phere, takes  from  it  two  equivalents  of  oxygen,  and  also  becomes 
nitrons  acid,  or  N04.  Hyponitrous  acid,  N03,  on  admixture  with 
water,  is  converted  into  nitric  acid  and  binoxide  of  nitrogen,  thus  : 
3N03  =  N05  -+-  2N02,  in  which  case  the  latter  will  be  converted 
into  nitrous  acid,  which,  in  the  presence  of  water,  is  converted 
into  nitric  acid  and  binoxide  of  nitrogen. 

It  follows  from  this  that,  if  oxygen  and  nitrogen  unite  at  all 
in  the  mouth,  let  the  proportions  be,  at  the  first,  what  they  will, 
nitric  acid  must  be  the  ultimate  result,  as  air  and  moisture,  the 
only  agents  necessary  in  the  transformation,  are  here  always 
present. 

The  reader  will  now  think  of  the  mucus,  and  particles  of  nitro- 
genous food  lodged  about  the  teeth  undergoing  decomposition,  and 
yielding  nitrogen  to  the  oxygen  of  the  atmosphere,  or  of  the  fluids 
of  the  mouth,  and  will  conclude  that  all  is  explained.  Well,  per- 
haps it  is.  But  let  us  consider.  Nitrogen  is  emphatically  a  "  con- 
servative "  element,  and  manifests  but  little  tendency  to  unite  with 
anything  and  especially  with  oxygen.  It  is  probable,  therefore, 
that  these  two  elements  unite  indirectly.  It  should  be  borne  in 
mind  that  organic  nitrogenous  bodies  contain  hydrogen  and  oxy- 
gen, as  well  as  nitrogen.  Consequently,  by  their  decomposition, 
these  elements  are  all  liberated.  The  mutual  affinities  of  hydrogen 
and  nitrogen  take  precedence,  and  the  result  is  the  formation  of 
ammonia,  Nil.,.  But  ammonia  exposed  to  the  action  of  oxygen  is 
always  decomposed  ;  oxide  of  nitrogen  is  formed,  and  of  course 
nitric  arid  is  the  result. 

With  this  view  of  the  case,  and  from  the  fact  that  many  persons 
permit  the  buccal  mucus  as  well  as  particles  of  nitrogenous  food 
to  remain  around,  upon,  and  between  the  teeth,  till  decomposition 
i-  effected,  it  is  not  surprising  that  the  white  variety  of  dental 
cariec  i-  bo  frequently  found. 


476  APPENDIX. 

Nitric  acid  is  also  sometimes  formed  in  the  mouth  by  the  agency 
of  galvanic  action.  When  two  metals  are  placed  in  the  mouth  in 
proximity  to  each  other,  ami  the  fluids  of  the  mouth  are  capable  of 

acting  on  one  of  them,  galvanic  action  is  established.  And  if  they 
are  so  situated  that  the  mucous  membrane  forms  a  connecting  con- 
ductor, by  being  in  contact  with  both,  especially  if  the  metallic 
surfaces  be  considerable,  a  current  is  established  sufficient  to  de- 
compose any  of  the  binary  compounds  contained  in  these  fluids. 
The  liberated  nitrogen,  hydrogen,  and  oxygen  will  result,  as  above, 
in  the  formation  of  ammonia,  and  then  nitric  acid.  But  galvanic 
action  in  the  mouth  is  more  likely  to  develop  hydrochloric  than 
nitric  acid.     This  will  be  noticed  again. 

Sulphuric  Acid. — Sulphuric  acid  is  composed  of  16  parts  of 
sulphur  united  with  24  of  oxygen.  Its  symbol  is,  therefore,  S<  >,. 
In  addition  to  those  properties  which  characterizes  it  as  an  acid,  it 
is  a  powerful  caustic  poison,  and  promptly  destroys  the  various 
tissues  with  which  it  comes  in  contact.  Its  chemical  action  on 
ordinary  tissues  depends  principally  on  its  affinity  for  water,  but 
not  altogether;  for  it  has  the  ability  to  coagulate  and  unite  with 
albumen,  and  to  dissolve  fibrin.  In  common  with  other  acids,  it 
has  a  strong  affinity  for  alkaline  bases. 

With  these  properties  in  view,  let  us  examine  its  action  on  the 
teeth. 

The  affiuity  of  this  acid  for  water  is  so  energetic  that  it  seems 
even  to  force  its  elements  to  forsake  favorite  combinations,  and  to 
unite  with  each  other,  that  it  may  be  gratified.  For  example,  a 
cork  iu  a  bottle  of  sulphuric  acid  becomes  dark-colored,  and  is 
really  charred.  Now  a  cork,  like  other  wood,  is  mainly  composed 
of  carbon,  hydrogen,  and  oxygen — the  latter  two  being  in  the 
proper  proportions  to  form  water.  Their  affinity  for  each  other, 
quickened  by  that  of  the  acid  for  the  result  of  their  combination, 
causes  them  to  forsake  the  carbon,  unite  with  each  other  to  form 
water,  and  then  combine  with  the  acid.  The  same  phenomena 
occur  when  it  acts  on  animal  tissues  ;  for  they  are  principally 
composed  of  the  above-named  elements,  with  the  addition  of  ni- 
trogen. Accordingly,  "  black  spots  are  frequently  observed  in 
the  stomachs  of  those  who  have  swallowed  the  acid."  Now,  that 
its  slow  and   prolonged  action  on  the   gelatinous  portion   of  the 


DENTAL   CARIES.  477 

tooth  would  result  in  its  carbouization,  is  a  conclusion  justified 
both  by  inference  and  experiment.  But  carbonized  gelatin  is 
"animal  charcoal,"  the  color  of  which  is  a  prominent  character- 
istic of  "  black  decay." 

The  phosphate  of  lime  in  the  tooth,  which  is  not  the  neutral, 
but  a  subphosphate,  is  not  soluble  in  sulphuric  acid,  nor  is  the  acid 
capable  of  decomposing  it,  except  in  the  presence  of  alcohol.  It 
follows,  then,  that  this  acid  does  not  break  down  the  texture  of 
the  tooth  to  the  extent  that  some  others  do,  simply  because  it  can- 
not unite  with,  or,  under  ordinary  circumstances,  decompose  the 
principal  earthy  salt  of  which  it  is  composed.  And  here  we  have 
a  second  characteristic  of  "  black  decay." 

It  is  now  time  to  inquire  whether  at  all,  and  if  so,  by  what 
means,  and  under  what  circumstances,  this  acid  is  brought  in  con- 
tact with  the  dental  organs. 

Sulphuric,  like  nitric  acid,  is  frequently  administered  as  a  medi- 
cine, and  generally  with  criminal  negligence  in  respect  to  its  ac- 
tion on  the  teeth.  But  we  cannot  regard  this  as  the  only  or  prin- 
cipal source  of  danger  from  this  acid.  If  oxygen  unites  at  all 
with  sulphur,  the  tendency,  under  ordinary  circumstances,  is  to 
the  formation  of  sulphuric  acid,  as  sulphurous  acid  in  the  presence 
of  moisture  is  rapidly  converted  into  the  sulphuric.  The  whole 
question,  then,  is  reduced  to  this:  Is  sulphur  ordinarily  present 
in  the  mouth,  and  liable  there  to  become  oxidized? 

Albumen  is  a  constituent  of  mucus,  and  is  contained  in  many 
articles  of  food.  Sulphur,  if  not  a  constituent  of,  is  always  united 
with  albumen.  Its  ordinary  presence  in  the  mouth  is,  therefore, 
easily  explained.  Sulphur  and  oxygen  unite  directly,  under 
various  circumstances,  as  in  the  combustion  of  sulphur,  but  it  is 
probabld  that  the  union  here  is  effected  by  indirect  means.  Hy- 
drosulphuric  acid,  or  sulphuretted  hydrogen,  is  one  of  the  results 
of  the  putrefactive  decomposition  of  albuminous  substances.  The 
breaths  of  our  patients  often  bear  ample  testimony  to  its  presence 
iu  the  mouth.  Now,  the  oxygen  of  the  atmosphere  rapidly  de- 
composes this  acid  by  taking  its  hydrogen  to  form  water.  The 
sulphur  i-  therefore  set  free,  and  being  in  its  nascent  state,  its  af- 
finities are  increased  in  energy,  and  it  also  unites  with  oxygen, 
forming  sulphurous  acid,  BOa>  which  in  the  presence  of  the  water 
of  the  -aliva  is  rapidly  converted  into  sulphuric  acid,  or  808. 


478  APPENDIX. 

The  quantity  of  sulphur  present  in  the  mouth  at  any  one  time 
is  very  minute,  and  a  great  proportion  of  this  is  exhaled  by  the 
breath  before  it  has  time  to  undergo  decomposition.  And  sul- 
phuric acid,  as  already  noticed,  has  a  weaker  affinity  for  the  con- 
stituents of  the  tooth  than  some  others.  Hence,  "  black  decay  " 
is  not  so  frequently  met  with  as  some  other  varieties.  And  as 
from  the  nature  of  the  chemical  action  the  texture  of  the  tooth  is 
not  so  entirely  broken  up,  the  carbonized  portion  protects  the 
parts  beneath  it.  This  variety  of  decay,  therefore,  progi 
less  rapidly  than  others. 

Hydrochloric  Acid. — This  acid  is  also  called  chlorohydric  and 
muriatic  acid.  It  is  composed  of  35  parts  of  chlorine,  united 
with  1  of  hydrogen.  Its  symbol  is  HC1.  Though  it-  elements 
rnauifot  a  strong  affinity  for  each  other,  yet  it  is  very  readily 
decomposed,  and  many  of  its  chemical  manifestions  result  from 
the  action  of  one  or  both  of  its  liberated  elements.  It  is  on  this 
principle  the  acid  attacks  metals — being  decomposed,  the  chlorine 
uuites  with  the  metal  to  form  a  chloride,  and  the  hydrogen  es- 
capes with  effervescence. 

This  acid,  like  those  previously  considered,  is  a  caustic  poison. 
Its  escharotic  power  depends  mainly  on  its  affinity  for  water, 
which  is  very  active,  and  on  its  ability  to  coagulate  albumen.  Its 
chemical  action  is  generally  inferior  to  that  of  the  two  acids  just 
considered.  It  uuites  with  bases,  forming  a  class  of  salts  called 
hydrochlorates,  and  sometimes  it  combines  with  a  salt  without 
decomposing  it.  or  being  itself  decomposed.  When  concentrated, 
it  dissolves  animal  tissues,  but  is  in  this  respect  far  inferior  to 
nitric  acid.  When  much  diluted,  and  mixed  with  dried  mucous 
membrane,  it  dissolves  coagulated  albumen,  fibrin,  etc.,  perform- 
ing to  all  appearance  an  artificial  digestion. 

A  careful  observation  of  these  properties  will  enable  us  to  un- 
derstand the  action  of  this  acid  on  the  tooth. 

The  carbonate  of  lime  and  the  acid  are  mutually  decomposed. 
The  results  are   chloride  of  calcium,  water,  and  carbonic  acid. 
The  decomposition  may  be  represented  by  the  following  equation: 
(  aO,C02  +  HC1  =  CaCl  +  HO  +  CO,. 

The  carbonic  acid,  of  course,  escapes  as  a  gas,  and  the  chloride, 
being  very  soluble,  is  dissolved  in  the  saliva,  and  thus  removed 
from  the  tooth. 


DENTAL   CARIES.  479 

The  phosphate  of  lime  (bone  phosphate),  though  not  decom- 
posed by,  is  highly  soluble  in  hydrochloric  acid.  It  is  dissolved 
and  is  thus  removed  from  the  organic  portion  of  the  tooth. 

We  have  seen  that  this  acid,  unless  highly  concentrated,  is  not 
capable  of  dissolving  the  animal  portion  of  the  tooth.  As  this 
concentration  is  not  likely  to  take  place  in  the  mouth,  it  follows 
that,  when  hydrochloric  acid  is  the  cause  of  deutal  caries,  the 
earthy  portion  is  dissolved  and  removed,  while  the  animal  por- 
tion principally  remains  in  the  carious  cavity.  And  here  we  have 
the  prominent  characteristics  of  a  third  variety  of  decay. 

I  have  not  taken  into  the  account  any  of  the  earthy  salts  con- 
tained in  the  tooth  but  the  phosphate  and  carbonate  of  lime. 
They  are  present  in  such  small  quantities  that  they  exert  but 
little  influence  on  any  of  the  chemical  actions  which  we  have 
considered. 

Hydrochloric  acid  is  also  administered  as  a  medicine,  and  the 
remarks  made  on  the  preceding  acids  apply  equally  here.  This 
acid  is  an  ingredient  of  the  gastric  fluid,  and  is  often  present  in 
abnormal  quantities  in  the  stomach,  from  which  it  is  thrown  into 
the  mouth  by  eructation  and  vomiting.  But  we  cannot  thus  ac- 
count satisfactorily  for  the  frequency  with  which  the  dental  organs 
are  evidently  injured  by  this  acid. 

Though  in  its  normal  state  the  saliva  is  alkaline,  yet  in  a  va- 
riety of  abnormal  conditions  it  contains  one  or  more  free  acids ; 
and  the  hydrochloric  is  one  of  those  most  frequently  present.  It 
often  originates,  no  doubt,  in  the  decomposition  of  the  soluble 
chlorides  contained  in  the  saliva  and  mucus.  "When  the  chlorine 
of  these  is  liberated  it  takes  hydrogen  from  the  water  of  the  saliva, 
and  this  acid  is  a  result  of  the  union. 

But  sometimes  hydrochloric  acid  is  directly  furnished  by  the 
salivary  glands,  either  as  a  secretion  or  an  excretion.  The  system 
may  contain  just  its  normal  quantity  of  chlorine,  but  if  there  be 
a  deficiency  of  sodium  or  potassium,  the  relative  excess  of  chlo- 
rine is  converted  into  hydrochloric  acid.  In  this  case  the  acid 
is  secreted.  Or,  the  quantity  of  potassium  and  sodium  may  be 
normal,  with  an  excess  of  chlorine.  The  excess  will  unite  as  be- 
fore with  hydrogen, and  the  acid  will  be  excreted.  At  all  events, 
this  acid  is  usually  found  in  the  mouth  when  the  mucous  mem- 


ISO  APPENDIX. 

brane  is  inflamed,  a<  well  as  in   patient-  who  indulge  in  thi 
cessive  use  of  salted  meats. 

Galvanic  currents  in  the  mouth  always  result  in  the  formation 
of  this  acid.  The  chlorides  of  sodium  and  potassium  presenl 
in  normal  mucus  and  saliva,  arc  decomposed,  and  their  chlorine 
unites  with  hydrogen  derived  from  the  water  of  the  saliva.  It 
is   on   this   principle  that  we  frequently  find  a  decayed  sui 

around  a  gold  filling  which   is   in   close  proximity  with  •  of  a 

different  metal,  or  with  a  silver  plate  or  clasp.  In  such  decays, 
the  animal  portion  usually  remains  while  the  earthy  portion  is 
removed,  just  as  would  be  expected  from  the  prolonged  action  of 
dilute  hydrochloric  acid. 

In  these  observations  we  have  endeavored  to  set  forth  the  re- 
sults of  the  ordinary  uninterrupted  action  of  these  acids  on  the 
teeth  ;  and  we  have  seen  that  they  are  capable  of  producing  the 
three  varieties  of  decay  usually  described,  though  we  by  no  means 
maintain  that  they  are  the  only  agents  capable  of  causing  these 
results.  Their  actions,  and  consequently  the  characteristics  of  de- 
cay produced  by  them,  are  doubtless  much  modified  by  circum- 
stances. One  of  them  may  be  the  destructive  agent  in  the  com- 
mencement of  the  caries,  and,  in  process  of  time,  another  may  be 
developed  and  exert  its  specific  influence  on  the  same  cavity. 
Then  the  phenomena  would  of  course  be  complex.  Again,  it 
should  be  remembered  that  a  strong  affinity  for  water  is  a  prop- 
erty common  to  all  of  them.  It  is  possible,  therefore,  that  car- 
bonization or  blackening  may  result  from  the  action  of  any  of 
them,  yet  it  is  by  no  means  probable,  at  least  with  nitric  acid. 


SECTION  B.— DR.  CORYDON   PALMER'S   PLUGGING 
INSTRUMENTS. 

Ix  the  following  pages  are  given  a  description,  and  the  mode  of 
using  Dr.  Palmer's  very  complete  set  of  plugging  instruments. 

They  are  illustrated  in  this  volume,  page  L32  I  Fig.  54).  The 
manner  of  using  them  is  so  explicitly  given  in  these  pages,  that 


DR.    PALMER'S   PLUGGING    INSTRUMENTS.  481 

no  one  of  experience  in  the  use  of  instruments  can  fail  to  apply 
them  as  intended. 

They  constitute,  altogether,  the  most  perfect  set  of  plugging  in- 
struments ever  devised.  They  more  nearly  meet  every  case  that 
may  be  presented  than  anything  heretofore  used. 

Several  instruments,  accessory  to  the  set,  are  here  described, 
that  are  not  illustrated  in  this  volume  ;  they  are  all,  however,  very 
valuable,  and  exactly  adapted  to  the  purpose  for  which  they  were 
designed.  ,  T. 

In  the  designing  of  these  instruments  for  the  profession,  it  has 
been  my  aim  to  perfect  a  set  that  shall  enable  the  operator  to 
reach  with  mallet  force  any  case  that  may  be  presented. 

A  course  of  practical  experiments  dating  back  to  the  intro- 
duction of  the  use  of  the  mallet,  has  brought  me  to  the  present 
designs. 

In  conducting  the  course,  my  object  has  been — First,  to  get  the 
best  adaptations  ;  second,  to  have  as  few  curves  as  possible  ;  and 
third,  the  least  number  of  instruments  that  will  do  all  the  work- 
and  lastly,  to  have  the  size  and  length  of  each  instrument  pro- 
portionate to  its  use. 

There  is  no  one  thing  that  we  owe  so  much  to  our  fellow-prac- 
titioners as  to  give  to  each  credit  for  what  he  does  toward  the  im- 
provement and  elevation  of  our  science. 

For  my  own  part,  I  do  not  claim  entire  originality  in  the  forms 
of  my  instruments.  For  principles,  I  am  indebted  to  our  worthy 
friend,  William  H.  Atkinson,  and  for  valuable  interchanges  to 
Charles  R.  Butler. 

All  instruments  for  mallet  forces  can  be  but  modifications  of  the 
foot.  My  efforts  have  been  to  produce  a  mallet  set,  to  be  used  in 
their  numerical  order,  that  shall  indicate  a  systematic  course  of 
operating. 

The  plugging  set  consists  of  thirty-five  pieces.  Up  to  No.  16, 
they  pertain  to  the  incisors ;  and  I  would  especially  recommend 
they  be  used  only  upon  these  teeth.  The  tendency  will  be  to  use 
them  in  every  case;  but  it  is  too  much  risk  for  such  fine  points. 

Do  not  pick  up  the  gold  upon  the  point  of  the  instrument  and 
hold  it  in  the  lamp,  as  it  will  quickly  destroy  the  temper. 

31 


482  APPENDIX. 

From  No.  17  to  30,  theiustrumeuts  pertain  to  the  bicuspids  and 

molars. 

Iu  order  to  describe  the  instruments,  we  must  suppose  a  case  : 

Left  superior  central,  anterior  approximal  surface,  cavity,  pre- 
pared with  fiue  retaining-pits  at  each  angle  of  the  cervical  wall. 

The  first  three  in  the  order  of  their  arrangement  are  cutting  in- 
struments, and  designated  by  dots  to  distinguish  them  from  the 
pluggers.  The'  first  one  is  a  fine  elastic  drill,  for  retaining-pits. 
The  second  is  a  fine  scoop  for  clearing  the  pit.  The  third  is  a 
curved  side-cut  for  clearing  the  last  particles  from  the  cavity 
proper.  These  three  instruments  are  indispensable  to  the  last  pre- 
paration of  the  cavity,  and  must  necessarily  be  classified  with  the 
pluggers  for  the  present ;  but  it  is  my  intention  that  they  shall 
comprise  the  last  and  higher  numbers  of  a  systematic  set  of  cutting 
instruments  to  be  brought  forward  in  due  course  of  time. 

The  two  instruments  Xo.  0,  are  holders  for  keeping  the  gold  in 
position  until  it  can  be  tacked  fast.  The  one  with  a  guard  in  the 
centre  is  to  be  used  when  no  assistant  is  at  hand  ;  and  when  held 
between  the  first  and  second  fingers,  the  guard  is  designed  to  pre- 
vent the  fingers  from  slipping  down.  The  rounded  top  will  be  use- 
ful upon  which  at  times  to  rest  the  forefinger  of  the  left  hand  at 
the  first  joint,  and  help  regain  position  of  the  fingers. 

Holders  are  important  instruments,  not  familiar  to  all.  I  would 
draw  attention  to  their  use.  I  feel  a  particular  pride  in  this  one 
new  design.  It  is  purposely  short,  in  order  to  bring  it*more  easily 
under  control ;  and  having  the  guard,  will  enable  the  operator  to 
hold  it  and  the  plugger  in  one  hand  at  the  same  time. 

The  manner  of  retaining  is  to  place  the  holder  betweeu  the  first 
and  second  fingers  of  the  left  hand,  letting  them  rest  upon  the 
guard,  and  place  the  plugger  between  the  thumb  and  forefinger, 
letting  the  points  of  the  instrument  cross  in  the  cavity. 

No.  0,  without  a  guard,  is  to  be  used  when  the  help  of  an  assis- 
tant is  at  hand,  and  taken  up  at  choice. 

The  two  holders  and  the  plugger  may  form  at  times  a  useful 
trio.  Used  without  an  assistant,  the  three  can  beheld  in  position 
by  the  left  hand,  and  the  stroke  given  by  the  right;  or,  with  assist- 
aut  help,  the  two  holders  in  the  left  and  the  plugger  in  the  right 
hand. 


DR.    PALMER'S   PLUGGING    INSTRUMENTS.  483 

The  maimer  of  holding  the  three  in  one  hand  is  to  place  the  two 
holders  in  position,  as  above  described,  and  then  add  the  plugger 
between  the  thumb  and  forefinger,  in  front  of  the  holders,  letting 
the  points  come  in  position.  With  assistant  help,  the  two  holders 
are  held  iu  position  as  above,  and  the  plugger  held  in  the  right 
hand. 

I  do  not  wish  to  be  understood,  that  the  holder  is  to  be  used 
throughout  an  entire  operation  ;  but  that  in  the  starting  of  a  fill- 
ing it  is  indispensable,  and  at  other  times  useful,  as  may  be  indi- 
cated. 

No.  1,  Pit  Point,  is  to  introduce  the  first  pieces  of  gold  into  the 
retainiug-pits,  and  fill  all  minute  cavities  upon  the  labial  surfaces 
where  ease  of  access  and  direct  force  can  be  had. 

No.  2,  Small  Foot,  is  to  introduce  the  first  pieces  of  gold  after 
the  pits  are  filled,  and  is  to  be  applied  until  the  gold  is  made  to 
extend  from  one  pit  to  the  other  and  firmly  attached. 

No.  3,  Foot,  is  to  add  a  portion  after  No.  2,  and  do  the  burden 
of  the  work  in  filling  the  cavity  even  with  the  edges  of  the  wall. 

No.  4,  Foot,  is  to  be  used  to  lay  the  gold  along  the  cervical  wall, 
by  letting  the  heel  pass  into  the  cavity,  and  the  point  project  ob- 
liquely beyond  the  edge  of  the  wall,  so  as  to  carry  the  gold  hard 
upon  and  perfectly  along  its  whole  line. 

No.  5,  Curved  Foot,  is  to  apply  upon  the  inner  surface  of  the  la- 
bial wall,  by  opening  the  mouth  and  applying  it  direct  from  the 
lingual  surface.  Its  curved  point  will  admit  of  its  being  brought 
in  contact  with  the  wall  with  less  danger  of  fracture  than  the  plane 
foot.  It  also  has  a  working  point,  which  may  be  applied  with 
directing  force  with  advantage. 

No.  fi,  Double  Serrated  Pit  Point,  is  to  carry  the  gold  into  the 
apex  of  the  cavity,  toward  the  cutting  edge  of  the  tooth.  This 
instrument  deserves  especial  notice.  It  enables  the  operator  to 
carry  the  gold  with  mallet  force  into  this  part  of  the  cavity  with 
ease  and  certainty.  It  must  be  used  with  careful  directing  force, 
and  can  be  applied  either  from  the  labial  or  lingual  surface. 

No.  7,  Sl<>>  Plugger,  applies  in  filling  the  slot,  extending  from 
the  apex  of  the  cavity  to  and  along  the  line  of  the  cutting  edge, 
or  wherever  slots  occur  upon  the  incisors. 

No.  8,  Lingual  Modeller,  applies  in  modelling  up  the  lingual 


484  APPENDIX. 

ridges  of  the  incisors.  Its  form  enables  the  operator  to  hold  the 
point  to  or  from  him,  without  danger  of  impinging  upon  the  ad- 
joining tooth.  By  opening  the  mouth,  direct  force  can  be  given. 
It  will  be  observed  that  this  and  several  of  the  other  instruments 
are  sloped  forward  in  the  handle,  in  order  to  favor  their  introduc- 
tion from  the  lingual  surface. 

No.  9,  Lingual  Mallet  Burnisher,  applies  in  the  last  condensing 
of  the  gold,  along  the  lingual  edges  of  the  cavity.  Held  at  an 
angle  bringing  it  to  bear  upon  one  of  its  sloping  faces,  it  can  be 
made  to  glide  along,  or  bring  the  point  more  to  bear  will  follow 
minute  lines,  as  may  be  desirejd. 

No.  10,  Curved  Cervical  Modeller,  applies  in  modelling  the  gold 
at  the  cervical  wall  of  both  the  incisors  and  bicuspids  ;  is  indispen- 
sable for  condensing  the  anterior  and  posterior  surfaces  of  bicuspid 
fillings.  It  will  be  found  to  reach  these  surfaces  most  admirably. 
By  applying  it  as  the  operation  progresses,  the  approximal  sur- 
faces' may  be  modelled  into  form. 

No.  11,  Curved  Approximal  Modeller,  applies  upon  the  approx- 
imal surface  of  the  gold,  after  the  cavity  is  filled  even  with  the 
edges  of  the  walls,  and  does  all  the  remainder  of  the  modelling  of 
this  part  of  the  filling.  The  gold  is  to  be  laid  on  in  fiat  pieces, 
and  the  instrument  applied  both  from  the  labial  and  lingual  sur- 
faces. Its  curve  enables  the  operator  to  pass  it  through  so  far 
between  the  teeth  as  to  easily  reach  all  parts  of  the  approximal 
surface.  This  instrument  forms  a  marked  feature  in  the  set,  and 
becomes  a  great  favorite. 

No.  12,  Curved  Crown  Modeller.  This  instrument  applies  upon 
the  cutting  edges  of  the  incisors  and  the  elongation  of  their  crowns, 
and  upon  all  the  teeth  where  direct  force  is  required  upon  a  flat 
surface. 

No.  13,  Curved  Cusp  Modeller.  In  the  operation  of  elongating 
the  crowns  of  the  incisors,  the  labial  and  lingual  surfaces  of  the 
gold  must  be  condensed  as  the  operation  progresses.  Direct  force 
is  not  admissible,  and  this  instrument,  held  at  an  angle,  meets  the 
case.     It  is  also  designed  to  model  cusps  and  fissures. 

No.  14,  Curved  Model  Separator,  applies  with  mallet  force  in 
effecting  a  separation  between  approximal  fillings  in  the  incisors, 
and  can  be  introduced  from  the  labial  or  lingual  surfaces,  as  the 
case  may  require. 


DR.    PALMER'S    PLUGGING    INSTRUMENTS.  485 

No.  15,  Side  Curved  Hand  Separator.  Useful  in  effecting  a 
separation  of  the  fillings,  same  as  No.  14. 

No.  16,  Curved  Hand  Burnisher,  for  the  last  condensing  and 
finish  of  the  filling  in  the  incisors. 

Nos.  17  and  18,  Foot  Instruments,  are  the  same  size  upon  their 
working  faces  as  Xos.  2,  and  3,  and  are  to  take  their  place  upon 
the  bicuspids  and  molars.  Being  designed  to  do  the  burden  of 
the  work,  they  are  made  stouter,-  and  with  less  angle  of  face,  and 
less  inuer  curve. 

No.  19,  Foot,  is  designed  to  lay  the  gold  upon  the  cervical  walls 
of  the  bicuspids  and  molars,  by  passing  the  heel  into  the  cavity, 
and  letting  the  point  project  beyond  the  edge  of  the  cervical  wall. 
Same  as  the  use  of  No.  4. 

No.  20,  Curved  Foot,  applies  upon  the  thin  curved  buccal  and 
lingual  walls  of  the  bicuspids  and  molars. 

No.  21,  Slot  P luggers,  used  wherever  slots  occur  upon  the  bicus- 
pids and  molars. 

No.  22,  Double-curved  Holder,  for  the  bicuspids  and  molars,  and 
wherever  a  curved  holder  is  required. 

No.  23,  Double-curved  Root  Plugger,  used  with  directing  force 
in  the  palatal  roots  of  the  superior  molars,  and  in  all  cases  where 
large  deep  root  cavities  occur.  It  is  the  first  of  a  class  of  eight' 
instruments,  purposely  designed  of  a  larger  size  than  the  previous- 
numbers,  in  order  to  enable  the  operator  at  times  to  grasp  the 
instrument  firmly  in  the  whole  hand,  and  give  directing  force. 

No.  24,  Double-curved  Croze-pointed  Plugger,  applies  in  the' 
deep  angles  of  the  posterior  cavities  of  the  inferior  bicuspids  and 
molars.     Used  with  firm  directing  force. 

No.  25,  Curved  Molar  Foot,  has  a  working  point,  and  is  de- 
signed to  introduce  all  the  gold  into  the  inferior  central  crown 
cavities  of  the  molars.  It  applies  with  the  use  of  the  holder,  by 
first  securing  the  gold  in  the  most  deep,  distal  part  of  the  cavity, 
and  then  working  forward,  extending  the  gold  along  the  sides  of 
the  cavity,  until  the  centre  is  passed,  and  then  turning  the  point 
of  the  instrument  and  working  backward  until  the  walls  of  the 
cavity  are  entirely  lined  up;  then  commence  and  bring  up  the 
centre  of  the  filling  to  finish.  This  instrument  is  one  of  the  most 
universally-acting  aud  rapid-working  points  with  which  I  am  ac*- 


486  APPENDIX. 

quainted.  It  admits  of  being  turned  to  and  from  the  operator, 
and  works  across  the  mouth  with  great  advantage.  The  position 
for  the  operator  for  the  right  inferior  molar  is  back  of  and  above 
the  patient.  For  the  left,  if  the  operator  is  skilled  in  the  use  of 
the  left  hand,  he  need  not  change  positions  ;  but  if  change  is  re- 
quired, stand  at  the  left  side  and  hold  the  instrument  with  firm 
directing  force. 

Nos.  26  and  27,  Right  and  Left  Treble-curved  Bicuspid  Pluggers, 
are  designed  to  introduce  the  gold  into  the  posterior  cavities  of 
the  inferior  bicuspids  and  molars.  The  opinion  has  largely  pre- 
vailed that  direct  mallet  force  could  not  be  brought  to  bear  upon 
this  class  of  cavities;  but  these  instruments  held  in  position,  will 
give  direct  forward  force,  and  can  be  worked  across  the  mouth 
with  great  satisfaction.  They  also  apply  upon  the  superior  bicus- 
pids and  molars  equally  well. 

Nos.  28  and  29,  Eight  and  Left  Treble-curved  Molar  Modellers, 
apply  at  the  posterior  cervical  walls  of  the  inferior  bicuspids  and 
molars,  and  serve  to  model  up  all  the  posterior  surface  of  the 
fillings,  enabling  the  operator  to  give  most  direct  forward  force. 
They  reach  a  point  that  no  other  instruments  will.  Posterior  lin- 
gual cusps  can  be  reached  with  these  instruments,  and  condensed 
upon  their  posterior  and  lingual  angles, — a  point  that  has  been 
hard  to  reach.  They  also  work  across  the  mouth  with  great  ad- 
vantage, and  can  be  applied  to  the  superior  bicuspids  and  molars 
as  well.  For  applying  the  instrument  to  the  right  inferior  molar, 
stand  at  the  back  of  and  above  the  patient,  holding  the  instrument 
firmly  in  the  whole  hand,  letting  the  thumb  rest  upon  the  shaft  of 
the  instrument,  and  next  the  cheek,  and  give  tense  directing  force. 
For  the  left,  stand  upon  the  left  side,  grasping  the  instrument 
firmly  with  the  whole  hand,  letting  the  fingers  go  next  the  cheek, 
and  the  thumb  firm  against  the  shaft,  and  give  tense  directing 
force. 

No.  30,  Modelling  JFullet  Burnisher,  has  a  combination  of  work- 
ing faces.  Held  at  an  angle  upon  one  of  its  sloping  faces,  it  can 
be  made  to  glide  along,  and  lay  additional  pieces  of  gold,  if  de- 
sired ;  or,  turned  more  upon  its  point,  will  follow  fine  lines  in  the 
modelling  of  cusps  and  fissures.  It  will  reach  the  posterior  sur- 
faces of  the  bicuspids  and  molars,  and  can  be  used  for  the  last 


DR.    PALMER'S    PLUGGING    INSTRUMENTS.  487 

hand  burnishing  of  fillings,  if  desired.     Used  with  the  mallet, 
must  be  grasped  firmly  in  the  whole  hand,  and  given  directing 

force. 

A  word  or  two  in  reference  to  the  fiuish.  The  instruments  are 
purposely  finished  bright  and  polished  throughout ;  because  in  a 
long  course  of  careful  practical  experiments,  I  have  found  that 
finished  in  this  way  they  keep  better,  and  are  more  pleasing  to  the 
eve.  After  the  brilliancy  of  the  first  finish  is  worn  off,  they  will 
assume  a  certain  dull,  silvery  surface,  which  makes  them  pleasant 
to  hold,  and  they  are  always  clean  and  presentable. 

The  Cases  are  made  from  a  new  design  of  my  own,  suited  to 
practice. 

They  contain  the  plugging  instruments,  four  pieces  of  forceps, 
a  foil  carrier,  and  dressing  ueedle;  all  of  which  are  new,  and  es- 
pecially designed  and  adapted  to  the  mouth  by  myself. 

No.  1  and  No.  2  are  punches  for  the  rubber  dam,  and  are  so 
formed  that  they  can  be  applied  to  put  in  new  holes  after  the  dam 
is  adjusted,  and  thus  enable  the  operator  to  extend  the  dam  with- 
out the  necessity  of  removing  it  from  the  mouth, — a  most  desirable 
feature  in  its  use. 

The  Wedge  Cutter  is  so  formed  and  curved  that  it  can  be  made 
to  reach  any  point  desired,  enabling  the  operator  to  cut  off  a  wedge 
far  back  in  the  mouth,  or  nip  a  point  along  the  lingual  surfaces 
of  the  teeth. 

The  Wedge  Forceps  is  an  entirely  new  instrument,  in  size  and 
form,  pleasant  to  the  hand  and  eye.  Its  curve  enables  the  opera- 
tor to  pas<  it  far  back  in  the  mouth,  to  reach  any  point  desired, 
and  insert  or  withdraw  a  wedge,  pull  off  a  dipt  ligature,  or  hold 
a  piece  of  wood  for  porte  polish,  to  apply  upon  the  lingual  sur- 
faces, particularly  the  inferior  incisors.  Must  not  be  used  for 
handling  eugiue  bits. 

The  Fail  Carrier  ie  to  be  used  for  picking  up  the  gold,  holding 
it  in  the  flame  of  the  spirit-lamp,  and  carrying  it  to  the  mouth. 
May  !>'•  used  also  for  introducing  and  removing  dressings.  Must 
be  held  between  the  thumb  and  forefinger,  letting  the  top  of  the 
instrument  pass  over  the  back  of  the  hand,  and  not  placing  the 
hand  on  the  top  of  the  instrument.  The  points  are  the  most  ad- 
vantageously curved  lor  its  application  to  all  parts  of  the  mouth. 


188  APPENDIX. 

This  foil  carrier  is  designed  to  be  useful  in  a  certain  mode  of  prac- 
tice whirh  I  wish  to  recommend,  and  thai  is  :  during  the  operation 
of  filling,  not  to  lav  down  the  foil  carrier,  but  place  it  between  the 
lips.  In  this  way  it  is  always  ready,  and  no  time  is  lost  in  hunt- 
ing for  it.  I  must  not  forgel  to  cautioD  against  the  danger  of 
letting  it  fall  in  the  face  of  the  patient,  and  hope  that  all  are 
thoughtful  enough  to  be  upon  their  guard  in  that  respect.  I  dwell 
a  little  upon  this  instrument  because  it  is  one  of  the  most  impor- 
tant and  first  looked  for  when  we  are  ready  to  fill.  It  is  not  in- 
tended to  be  used  as  a  plugger,  and  is  made  purposely  light,  and 
not  with  too  stiff  a  spring,  so  that  it  can  be  held  as  above  described, 
without  an  unpleasant  -train  upon  the  lips,  and  yet  tempered  and 
stitf  enough  through  the  body  and  points  not  to  bend  when  used 
to  insert  or  remove  a  dressing. 

Dressing  Needle. — Although  this  instrument  has  its  more  ex- 
tended range  of  usefulness,  it  is  so  inseparable  from  the  opera- 
tion of  filling,  that  I  consider  the  case  would  be  incomplete  with- 
out it. 

In  the  last  preparation  of  a  cavity,  particularly  where  there  are 
sensitive  surfaces,  it  is  desirable  to  give  a  dressing  before  intro- 
ducing a  filling.  This  instrument  is  the  one  best  suited  to  the 
purpose. 

In  case  of  dressing  over  exposed  nerves,  to  allay  pain,  the 
rounded  top  will  be  useful  to  fix  the  cotton  smoothly  in  position. 

In  conclusion,  let  me  say,  that  the  instruments  are  designed  to 
be  graceful  in  form,  artistic  in  finish,  proportionate  in  size  and 
length — each  one  having  its  particular  use — together  forming  one 
systematic  whole. 


SECTION  C— MALLETS. 


The  Electromagnetic  Mallet.— Electro-magnetism  has, 
within  the  last  eight  or  ten  years,  been  applied  and  used  as  a 
motive  power  for  the  automatic  plugger. 

The  plugging  instrument  operated  by  this  force,  though  not  in 
general  use  (and  perhaps  never  will  be),  yet  by  some  it  is  prized 
very  highly,  and  used  with  great  efficiency. 


MALLETS.  489 

To  those  unacquainted  with  electric  force,  and  the  appliances 
through  which  to  make  it  available,  this  instrument  will  appear 
complicated  and  difficult  to  keep  in  proper  condition,  but  to  those 
familiar  with  it,  it  is  easily  controlled  and  managed. 

The  following  extracts  from  a  paper  on  the  electro-magnetic 
mallet,  by  Dr.  Louis  Jack,  is  so  directly  to  the  point,  that  we  can 
hardly  do  better  than  present  them  here. 

He  says  :  "  The  first  attempt  to  take  advantage  of  electro-mag- 
netism for  this  purpose,  it  would  appear,  must  be  credited  to  Mr. 
G.  F.  Green,  who  first  produced,  according  to  his  own  statements, 
an  instrument  in  which  he  made  use  of  the  power  which  a  heliacal 
coil  has  to  draw  within  it  towards  its  middle  a  piece  of  iron  sus- 
pended, or  temporarily  held  at  its  either  end. 

"  At  each  influx  of  the  electrical  current  the  suspended  iron 
would  fly  to  the  centre  with  quickness,  to  be  stopped  by  the 
plugger  end,  arranged  to  meet  it  at  that  point ;  at  this  moment 
the  current  was  shut  off,  when  the  mallet  would  fly  back  under 
the  force  of  a  spring,  only  to  return  again  by  the  recurrent  open- 
ing of  the  circuit. 

"The  experiments  with  this  class  of  electric  pluggers  have 
proven  unsuccessful." 

Mr.  Green  made  other  experiments  which  were  equally  unsuc- 
cessful. 

Dr.  Jack  further  remarks:  "Entirely  independent  of  any 
knowledge  of  what  Mr.  Green  had  been  doing  in  this  direction, 
Dr.  Bonwill,  after  watching  the  working  of  the  armature  in  the 
magnetic  telegraph,  conceived,  with  true  inventive  talent,  the  idea 
of  utilizing  this  arrangement,  and  with  the  necessary  modifica- 
tions and  adaptations  to  employ  the  force  which  impacts  the  style 
upon  the  paper,  in  the  delivery  of  the  same  quick  blows  upon 
the  plugging  point.  He  therefore  attached  his  armature  by  its 
middle  upon  a  point  at  a  distance  relatively  far  from  the  electro- 
magnet, making  the  armature  act  as  a  mallet.  Thus  was  secured 
a  Light  and  intense  blow,  and,  as  the  armature  moved  through  a 
small  distance,  gained  the  additional  quality  of  rapidity  ;  a  com- 
bination of  qualities  of  the  highest  importance,  rendering  his  in- 
strument practically  efficient. 

"  Dr.  Bonwill  has,  from  time  to  time,  improved  his  first  instru- 
ment, until  we  now  have  from  his  hands  one  which  has  proven 


490  APPENDIX. 

satisfactory  in  most  respects.  To  him,  therefore,  we  are  indebted 
for  the  first  useful  electro-magnetic  mallet." 

After  Dr.  Bon  will  had  arrived  at  a  point  in  the  construction  of 
this  instrument  beyond  which  he  concluded  not  to  go,  Dr.  Jack 
made  some  modifications  of  the  instrument,  the  purport  of  which 
may  be  inferred  from  the  following  extracts  : 

"  The  objects  of  this  inveution  are  to  render  the  movements 
simpler  and  more  direct  thau  has  heretofore  been  done,  with  the 
ends  in  view  to  produce  a  sharp  and  decided  impact;  to  lessen 
the  sounds  of  the  movement  at  both  the  time  of  the  impact  and 
recoil,  and  to  produce  a  lighter,  cheaper,  more  convenient,  and 
agreeable  instrument. 

"The  principal  feature  of  this  invention  consists  iu  the  form 
given  to  the  electro-magnet.  The  core  is  made  the  segment  of  a 
cylinder,  so  that  when  the  helices  are  formed  and  placed  to- 
gether they  produce  a  more  or  less  cylindrical  body,  leaving 
between  them,  at  the  central  part,  a  circular  aperture  for  the 
reception  of  a  small  cylinder. 

"  This  cylinder  receives  a  plugger,  which  imparts  the  force  of 
the  armature  upon  the  plugger,  and  at  the  same  time  permits  free- 
dom of  movement  and  gives  direction  to  the  armature. 

"  There  are  other  improvements  depending  upon  this  one,  and 
connected  therewith,  viz. : 

"The  form  of  the  armature  and  its  connected  parts. 

"  The  form  and  arrangemeut  of  the  circuit-closer. 

"The  form  and  arrangement  of  the  interrupter. 

"  The  device  employed  to  deaden  the  recoil. 

"  The  means  of  securing  the  adjustments  of  the  instruments. 

"The  best  results,  and  the  least  discomfort  of  the  patient  are 
secured  by  careful  attention  to  the  adjustments. 

"  It  should  be  noticed  in  this  connection  that  the  greatest  econ- 
omy will  be  found  in  having  the  batteries  in  clean  condition,  re- 
plenished to  good  strength,  and  the  zinc  plates  kept  freely  amal- 
gamated." 

In  a  paper  on  the  electro-magnetic  mallet,  by  Dr.  E.  T.  Darby, 
July,  1875,  in  speaking  of  the  advantages  which  the  electric 
mallet  possesses  over  all  other  instruments  intended  for  the  pur- 
pose of  consolidating  gold  in  the  operation  of  filling  teeth,  he 
says:  "  It  is  purely  automatic  in  its  action. 


MALLETS. 


491 


"  Its  power  or  force  is  entirely  distinct  from  anything  physical 
•or  individual,  except  the  will  of  the  operator  and  the  touch  of  his 
educated  finger. 

"  No  more  physical  force  is  required  to  manage  it  than  would 
guide  a  pen  or  hold  a  pencil. 

"  The  dentist  may  stand,  or  sit  in  his  chair,  hour  after  hour, 
and  feel  no  greater  fatigue  than  would  naturally  result  from  re- 
strained position  or  concentrated  thought. 

"  Nor  is  it  a  labor-saving  instrument  only,  it  is  a  time-saving 
invention  also. 

"The  length  of  time  required  to  thoroughly  pack  the  gold  in 
most  cavities  is  lessened  at  least  one-half  by  the  aid  of  the  electric 
mallet. 

"  Nor  is  it  a  time-saving  instrument  only,  it  is  a  pain-saving  ap- 
pliance as  well. 

"  The  blow  produced  by  the  electric  mallet  is  sharp  and  quick, 
and  does  not  jar  the  tooth  like  the  hand  mallet,  or  some  other 
automatics. 

"  The  operator  must  be  skilled  in  its  use,  otherwise  he  will  fail 
to  accomplish  the  best  results." 

The  paragraphs  above  quoted  from  the  two  papers  referred  to 
on  the  electric  mallet,  indicate  about  an  average  estimate  enter- 
tained by  those  who  have  become  thoroughly  familiar  with  its  use. 

The  following  illustration  shows  the  present  improved  form  of 
the  instrument. 

Fig.  128. 

L 


Description  of  Electro-magnetic  Mallet  of  l>r.  Bonwill. — No.  1, 
$-Bize.  E,  the  horseshoe  magnet.  M,  the  brass  frame  fixed 
firmly  to  magnet  al  the  top,  and  boldipg  the  arm  O,  at  L,  on  two 


492 


APPENDIX. 


pivoted  screws.  R,  hard  rubber  handle,  with  tool  P  running 
through  it  and  extending  as  far  to  the  right  under  the  hammer  as 
A.  K,  slide  key,  upon  which  right  index  finger  rests  for  making 
the  circuit,  and  causing  the  blows  in  rapid  succession  by  simply 
pushing  slide  or  key  forward.  F,  the  ring  through  which  right 
index  finger  passes  and  supports  the  mallet  and  prevents  falling. 
Thumb  rests  on  tool  just  below  K,  and  revolves  tool  in  any  direc- 
tion. J,  an  eccentric  screw-head  to  regulate  the  slide  K,  to  make 
it  of  very  delicate  touch.  L,  posts  into  which  the  flexible  wires 
from  battery  go.  N,  spiral  spring  inside  for  throwing  the  arma- 
ture O  back  against  the  check  screw-head  C,  which  head  also 
opens  or  closes  to  control  the  distance  the  hammer  travels.  H, 
screw  to  regulate  strength  of  spiral  spring  in  N.  D,  B,  and  A, 
the  automatic  brake  which  controls  the  number  of  blows  of  ham- 
mer. B,  screw-head  for  raising  or  lowering  to  permit  the  tool  to 
always  keep  the  right  distance  to  be  struck  by  armature  or  ham- 
mer. Makes  500  to  3000  blows  a  minute.  Weight  eight  ounces 
avoirdupois. 

Mallet  No.  2. — This  is  exact  size  of  magnets  and  the  frame.     It 
weighs  but  6£  ounces  avoirdupois. 


H,  horseshoe  magnets,  very  compact.  L,  the  armature,  with- 
out frame  or  hammer  thereon.  A,  screw  to  regulate  the  spring 
of  the  circuit-breaker.  B,  posts  for  attaching  flexible  wire  from 
battery  C,  automatic  brake,  which  is  struck  by  point  of  spring 
F,  and  is  always  pressing  hard  thereon.  E,  screw  regulator  of 
tool,  permitting  it  to  let  head  of  tool  project  enough  to  move 


MALLETS. 


493 


forward  about  one-fiftieth  of  an  inch  when  struck  by  M  on  the 
end  of  brake  C.     G,  handle  of  hard  rubber. 

This  is  now  as  complete  as  can  well  be  made.  The  first  instrument 
weighed  one  pound.  This  last  is  all  we  could  ask  in  size  and 
weight,  as  well  as  shape.  The  handle  and  the  hammer  on  the 
armature  are  not  shown  in  the  cut  of  this  mallet,  nor  is  the  ring. 

They  are  both  ruu  by  three  cups  of  smallest  size  Bunsen  Coke 
Battery  ;  it  costs  about  15  cents  a  week  to  charge  them.  These  are 
the  only  practical  electro-magnetic  mallets  now  in  use.  As  to 
saving  of  time,  it  has  been  claimed  by  the  inventor  that  he  has 
packed  one-quarter  ounce  foil  in  one  hour  fifteen  minutes.  It 
will  save  three  out  of  four  hours,  and  nearly  all  the  labor. 

Automatic  Plugger  for  Engine. — This  instrument  is  the 
invention  of  Dr.  T.  L.  Buckingham,  and,  as  the  caption  indicates, 
is  operated  by  the  dental  engine.  Those  who  have  used  the  in- 
strument and  are  most  familiar  with  it  claim  that  it  possesses  every 
available  quality  for  such  an  appliance.  The  blow  is  given  by  a 
spring,  and  is  entirely  under  the  control  of  the  operator;  it  is 
regulated  by  a  set  screw  on  the  head  and  a  movable  collar  on  the 
hand-piece.  The  latter  can  be  moved  at  will  during  the  operation 
of  the  instrument,  regulating  the  stroke  from  the  strongest  required 
to  the  lightest  appreciable  touch  ;  or  the  blows  can  be  suspended 
altogether  and  the  instrument  used  as  a  hand  plugger,  and  that, 
too,  without  stopping  the  engine. 

The  requirements  of  delicate  operations  needing  special  and  pre- 
cise manipulation,  are  well  met  by  the  skilful  use  of  this  instru- 
ment. 

The  bit-holder  is  movable,  and  is  drawn  back  after  each  blow 
by  a  small  spiral  spring  attachment. 

The  instrument  as  ordinarily  used  gives  about  eighteen  hundred 
blows  per  minute,  but  the  number  can  be  greatly  reduced  by  a 
simple  change  in  the  machinery,  which  can  be  effected  in  a  few 
moments,  and  thus  the  blows  reduced  to  less  than  one  hundred 
per  minute. 

The  points  used  in  this  are  such  as  are  in  common  use  with  au- 
tomatic mallets. 

A  ring  accompanies  this  instrument,  which  being  attached  to  it 
will  aid  the  operator  in  holding  and  directing  it  while  operating. 
it  ia  represented  by  the  following  cut  (Fig.  180). 


494 


MATRICES    FOR    PROXIMAL    FILLINGS.  495 

Hyde's  Pneumatic  Plugger. — This  instrument  was  devised 
aud  introduced  to  the  profession  about  1870.  It  consists  of  a 
small  cast  iron  frame,  to  which  is  attached  a  small  cylinder,  which 
with  its  piston  serves  as  an  air  pump  ;  this  is  operated  by  fly  and 
drive  wheels,  which  are  arranged  in  the  frame  and  operated  by  the 
foot. 

To  the  cylinder  is  attached  a  rubber  tube  about  seven  feet  in 
length  ;  to  this  is  attached  the  hand-piece,  within  which  a  plunger 
plays  ;  when  in  motion  this  communicates  its  impulses  to  the 
plugger. 

As  the  plugger  in  the  cylinder  is  driven  to  and  fro,  the  hammer 
in  the  hand-piece  responds,  expending  its  force  upon  the  socket- 
piece  that  holds  the  plugging  point. 

The  blow  is  direct  and  elastic,  as  the  piston  or  hammer  is  with- 
drawn the  moment  the  blow  is  given. 

The  rapidity  of  stroke,  as  well  as  the  force,  is  completely  under 
the  control  of  the  operator. 

This  instrument,  in  the  hands  of  those  who  have  become  familiar 
with  it,  is  very  efficient  and  easily  operated. 

A  modification  of  this  instrument  lias  been  made,  which  consists 
of  substituting  a  rubber  ball,  about  three  inches  in  diameter,  for 
the  frame,  wheels  and  cylinder  ;  and  the  operation  is  effected  by 
working  the  foot  upon  the  ball.  This  certainly  has  the  advantage 
of  being  much  more  simple. 


SECTION  D.— MATRICES  FOR  PROXIMAL  FILLINGS. 

To  Dr.  Louis  Jack  belongs  the  honor  of  devising  and  putting 
into  practical  form  the  matrices  as  aids  in  filling  teeth. 

Hi-  description  of  these  appliances, and  the  manner  of  using 
them,  is  so  concise  and  complete,  that  we  have,  with  his  consent, 
transferred  it  almost  wholly  to  these  pages.  By  a  careful  study 
of  the  directions  here  given,  almost  any  one  of  good  manipulative 
ability  will  be  able  to  use  them  with  good  results.  T. 


496  APPENDIX. 

"The  first  step,  in  case  the  teeth  are  in  close  contact,  is  to  sepa- 
rate them,  either  hy  pressure,  or,  as  in  so  extensive  caii<-  as  is 
under  consideration,  hy  a  parallel-sided  file  ;  and  from  this  slight 
separation  rapidly  and  freely  open  by  cutting  down  the  enamel  at 
the  middle  of  the  space,  afterwards  increasing  somewhat  freely 
with  the  chisel  the  inner  portion  of  the  opening.  Auother  plan  I 
sometimes  pursue,  where  no  fracture  of  the  masticating  plate  has 
occurred,  is  to  pass  a  small  five-sided  drill  until  it  fails  to  meet 
with  resistance,  increasing  by  a  larger  drill  ;  and  from  these  two 
half  circles  I  cut  in  either  direction  with  suitable  chisels  by  care- 
fully splitting  down  the  enamel, — first  the  masticating  portion, — 
and  continuing  until  a  free  space  is  secured  on  the  inner  side;  then 
more  carefully  opening  towards  the  buccal  division,  until  a  slight 
space  is  made  at  this  point.  The  file  may  be  used  at  this  stage  to 
further  open  the  space,  and  in  bringing  the  surfaces  into  proper 
shape  and  smoothness.  When  the  cavities  are  so  large  as  is  as- 
sumed above,  there  will  usually  be  found  so  much  disorganization 
of  the  enamel  as  to  render  necessary  so  much  cutting  to  procure  a 
healthy  surface  as  will  open  a  space  abundantly  large  for  the  sub- 
sequent work.  If  more  is  needed,  it  is  secured  by  wedging ;  in 
any  case  a  separation  as  large  at  the  lower  part  as  a  No.  7  Froid 
file,  and  at  the  cervical  part  as  a  No.  3,  is  easily  secured.  The 
buccal  space  should  be  but  slightly  wedge-shaped,  and  somewhat 
smaller  than  the  palatal,  for  reasons  which  will  appear  in  the 
proper  place. 

"After  removing  the  softer  caries,  the  walls  of  the  cavity  are 
prepared  for  the  reception  of  the  filling ;  the  overhanging  masti- 
cating plate  being  first  cut  away  in  a  circular  form  on  a  line  with 
the  bottom  or  pulp  wall,  so  that  by  direct  approach  every  part 
of  the  cavity  is  accessible  to  slightly  curved  or  even  straight  in- 
struments. This  opens  the  whole  cavity  to  view.  The  instru- 
ment best  adapted  for  this  purpose  is  the  gouge-shaped  chisel, 
which  cuts  with  exceeding  keenness,  and  produces  the  form  de- 
sired at  this  part.  The  removal  of  this  portion  of  the  enamel  is 
an  importaut  and  indispensable  step  in  the  improvement  I  am 
pursuing.  It  is  practiced  by  the  better  operators  to  a  somewhat 
less  degree,  and  is  in  many  cases  an  advantage  to  the  organ.  No 
other  argument  to  defend  this  course  may  be  used  than  that  in 


MATRICES    FOR   PROXIMAL   FILLINGS.  497 

these  fillings,  so  difficult  of  execution,  everything  subservient  to 
better  performance  must  be  followed  out  which  is  not  injurious  to 
the  strength  and  preservation  of  the  organ.  It  will  often  prove 
true  here,  as  elsewhere  in  surgery,  that  something  must  be  taken 
to  save  the  remainder. 

"  The  cervical  wall  is  now  cut  at  a  right  angle  to  the  proximal 
surface,  taking  care  to  remove  from  the  surface  of  the  tooth  be- 
neath the  gum  any  half-decomposed  enamel  which  may  be  pres- 
ent at  this  part.  No  retaining-groove  or  pits  are  needed  on  this 
wall. 

"  The  buccal  and  palatal  walls  are  next  smoothly  cut,  and  on 
the  side  of  each,  where  they  have  sufficient  strength,  a  shallow, 
round-bottomed  groove  is  made  the  whole  length,  and  terminat- 
ing at  the  very  surface  of  the  masticating  plate  of  enamel.  The 
outer  retaining-groove  should  be  near  the  margin,  to  avoid  any 
approach  to  the  pulp  ;  the  inner  one  should  be  nearer  the  bottom 
of  the  cavity,  so  that,  in  the  subsequent  cutting  away  of  a  por- 
tion of  the  palatal  wall  in  the  finishing  process,  the  hold  of  the 
gold  may  not  be  obliterated.  The  instruments  best  adapted  for 
this  grooving  are  made  by  filing  a  straight  point  quite  round  and 
small,  then  bending  at  a  suitable  angle,  and  shaping  so  as  to 
have  the  edge  at  the  inner  side  of  the  curve.  Instruments  of 
this  form  are  better  adapted  for  cutting  the  hard  dentine  and 
enamel  than  any  others,  for  the  reasons  that  they  may  be  made 
harder  than  usual  without  danger  of  breakage  ;  they  cut  with 
more  keenness,  do  not  chatter,  leave  the  surface  without  sharp 
lines,  and,  in  grooving,  each  cut  follows  the  last  with  certainty. 
They  are  directly  reverse  in  form  to  the  hoes  and  excavators  in 
general  use. 

"The  pulp-wall  of  the  cavity  is  not  altered  in  the  form  it  pre- 
sents after  the  removal  of  the  caries. 

"The  next  and  very  important  step  is  to  remove  the  sharp  corners 
of  the  mouth  of  the  cavity,  and  at  every  part  well  polish  it  with 
pumice-stone;  this  facilitates  the  passage  of  the  gold  over  the 
surface,  and  the  perfect  contact  of  the  foil  with  every  part.  This 
polishing  is  rapidly  done  by  rotating  a  piece  of  boxwood  armed 
with  pulverized  pumiee. 

Selection  is  now  made  of  one  of  the  appliances  figured  below,, 

32 


498  APPENDIX. 

which  are  inteuded  to  give  form  to  the  outer  surface  of  the  filling, 
and  are  called  matrices  for  this  reason.     These  little  affairs  are 
made  of  a  variety  of  shapes,  sizes,  and   thickness.     They  are 
,,   .  formed   of  slightly  wedge-shaped   pieces  of  steel, 

and  are,  as  the  cut  designates,  hollowed  out  at  their 
thicker  edge,  which  depression  terminates  at  the 
thinner  edge.  At  the  part  of  the  depression  de- 
signed to  give  shape  to  the  buccal  edge  of  the  filling  the  cut  is 
generally  abrupt  and  deep;  at  the  inner  portion  it  is  more  shal- 
low and  more  incliued.  It  will  be  observed  that  the  depression 
widens  as  it  passes  toward  the  thinner  edge  to  follow  the  usual 
form  of  proximal  cavities.*  The  lower  and  thin  edge  is  rounded, 
to  outline  the  curved  margin  of  the  cervical  wall,  and  to  effect 
pressure  upon  either  the  gum  or  the  appliances  used  to  stop  the 
escape  of  mucus  and  blood  from  this  tissue. 

"  The  plane  parts  of  the  face  are  file-cut  or  coarsely  draw-filed. 
The   reverse  side,  represented  in   Fig.  131,  and  which  for  con- 
venience of  description  is  divided  into  three  sections,  is,  in  most 
cases,  plane  and  smooth,  except iug  at  the 
section   c,  which   is  file-cut.     It  is  often 
a — '&    ^~0  necessary  to   have  this  side    in  two  sur- 

•Il'l'Ss^—™/  faces,    one   section,    a,   parallel   with   the 

plane  parts  of  the  face,  and  from  this 
point  inclining  to  a  thin  edge.  A  very  desirable  form  is  to  have 
section  c  bent  backwards  to  follow  the  incline  of  the  proximate 
tooth  beneath  the  gum.  At  each  end  a  square  cut  is  made  to  fit 
F  .„„  the  plier  ends  represented  at  Fig.  133.  After 
being  formed  they  are  protected  from  oxidation, 
heated  to  redness,  plunged  in  the  cold  bath,  and 
temper  drawn  to  near  blueness;  after  polishing 
the  depression  they  will  be  ready  for  use.  Quite  a  number  of  pairs 
are  necessary  to  meet  the  requirements  of  the  differing  cases,  but 
for  the  ordinary -sized  simple  proximal  cavities  a  dozen  pairs, 
varying  in  width,  in  thickness,  and  in  size  of  depression,  are  all 
that  I  have  found  necessary.     Fig.   131    represents  the  largest 


*  In  Fig.  131  the  boundary  of  the  right  end  of  the  depression  should  be 
similar  to  the  other  end. 


X 


MATRICES   FOB    PROXIMAL   FILLINGS.  499 

size  required,  those  iu  most  use  not  being  more  than  from  one- 
half  to  two-thirds  this  width  and  thickness.  The  character  of 
these  modifications  will  depend  somewhat  upon  the  desired  end, 
since  either  a  flat  contour  or  excessively  convex  surface  may  be 
produced  at  the  pleasure  of  the  operator,  or  to  suit  the  needs  of 
the  individual  operation,  by  varying  the  form  and  depth  of  the 
depression.  It  is  also  occasionally  necessary  to  have  a  matrix 
of  unusual  form  to  meet  special  cases,  where  the  space  is  ex- 
tremely great,  or  where,  from  the  fracture  of  the  outer  plate  of 
enamel,  a  steel  one  will  not  remain  in  position  ;  for  this  purpose 
I  have  found  hard  boxwood  to  answer  quite  well.  Silver,  also, 
in  such  cases,  will  occasionally  be  found  useful.  I  sometimes 
take  an  impression  of  the  immediate  part  to  assist  me  in  the 
fabrication  of  a  suitable  appliance.  I  have  also  made  double- 
faced  ones,  which  are  so  formed  as  ou  oue  adjustment  to  allow 
both  cavities  to  be  filled.  For  isolated  teeth,  having  large  pos- 
terior cavities,  a  ring  of  silver  may  be  used,  carrying  out  the  same 
principle  in  forming  the  portion  which  bounds  the  cavity.  I  have 
used  the  same  plan  iu  buccal  cavities. 

"The  selected  matrix  should,  at  the  convex  edge,  be  a  little 
thinner  than  the  space  between  the  teeth  at  their  closest  part  by 
the  gum  ;  it  should  pass  above  the  edge  of  the  cervical  wall,  and 
should  conform  at  this  part  to  the  contour  of  the  tooth  ;  the 
lower  and  thicker  edge  should  reach  nearly  to  the  masticating 
surface,  and  this  edge  should  not  entirely  fill  the  lower  part  of 
th»-  space;  above  all,  the  depression  at  every  part  of  its  border 
should  extend  slightly  beyond  the  edge  of  the  civity. 

"  After  having  secured  the  cervical  part  of  the  case  from  the 
encroachment  of  moisture,  by  means  of  the  rubber  dam,  or,  when 
this  is  not  applicable,  wedges  of  wood,  little  rings  of  india-rub- 
ber, the  string-dam,  short  pieces  of  waxed  twine,  of  such  size  as 
to  remain  firmly  in  place  when  drawn  between  the  teeth,  the  ap 
plication  of  dilute  chloride  of  zinc,  etc.,  or  a  combination  of  two 
or  more  of  these  means,  the  matrix  is  taken  up  in  the  pliers 
133  ami  pushed  upward  until  it  presses  upon  the  gum  or 
the  appliances,  and  until  it,  impinges  tightly  bet-ween  the  teeth. 
It  i-  now  wedged  firmly  against  the  tooth  to  he  operated  upon 
with  little  boxwood  wedges;  these  secure  it  in  place  during  the 


500  APPENDIX. 

packing.  Tt  is  well  usually  to  insert  two  wedges,  one  from  the 
buccal  side  between  the  teeth  near  the  margin  of  the  gums,  and 
one  from  the  palatine  or  lingual  side,  nearer  the  masticating 
surface  of  the  teeth  than  the  margin  of  the  gum;  thus  the  ma- 
trix will  he  firmly  keyed  to  it.s  proper  position.  When  the 
matrix  passes  up  to  the  proper  point,  the  wedging  towards  the 
cavity  throws  the  lower  edge  against  and  somewhat  beneath  the 
projecting  swell  of  enamel  of  the  neighboring  tooth,  which  adds 
to  the  security.  However  tightly  the  matrix  may  fit  between 
the  teeth,  it  will  not,  frequently,  retain  its  fixedness  unless 
curely  wedged.  Boxwood  answers  for  this  purpose  better  than 
any  substance  I  have  employed,  for  the  reason  that  it  is  so  hard 
as  to  be  unyielding,  and  on  this  account  also  does  not  require  to 
be  more  than  pushed  into  the  space.  The  wedges  should  be  made 
to  conform  in  size  aud  shape  to  the  space  they  are  intended  to 
occupy,  in  order  that  they  may  the  more  firmly  retain  their  po- 
sition when  inserted.  Moistening  them  with  a  solution  of  gum 
sandarac  or  mastic  adds  much  to  their  security  in  position  after 
they  are  introduced.  The  pliers  (Fig.  133)  are  adapted  to  their 
introduction. 

"  In  case  the  adjoining  teeth  are  not  in  contact  it  is  always  neces- 
sary to  introduce  a  wedge  between  them,  to  give  greater  firmness 
to  the  teeth  and  less  discomfort  to  the  patient.  In  all  large  cav- 
ities I  fix  the  matrix  previous  to  introducing  the  napkins.  Where 
the  rubber  dam  is  required,  it  precedes  this  appliance,  which  may 
aid  in  keeping  the  rubber  in  place. 

"  For  the  small  cases,  the  drying  is  done  first,  the  napkins  ap- 
plied, and  a  hard  rope  of  bibulous  paper  is  passed  against  the  gum, 
followed  by  the  matrix.  Fig.  134  represents  the  appearance  of  the 
parts  at  this  stage,  except  the  wedges,  which  are 
Fig.  134.  noj.  snovvn-  When  the  cavity  is  now  examined, 
it  will  be  found  to  present  an  open  mouth,  formed 
by  its  curved  lower  edge  of  enamel,  and  by  the 
boundary  of  the  matrix,  through  which  fuunel- 
shaped  opening  every  part  of  the  space  is  easily 
seen  and  directly  touched.  The  case  is  now  ready  for  the  recep- 
tion of  gold. 

"  I  use  for  the  upper  half  or  more  of  the  filling,  ribbons  of  Nos. 


MATRICES    FOR   PROXIMAL   FILLINGS.  501 

4,  5,  or  6,  of  non-cohesive  gold,  not  annealed.  These  ribbons  are 
made  of  one-fourth  to  whole  sheets  of  foil,  depending  on  the  size 
of  tbe  space,  and  then  folded  into  blocks,  varied  in  length  by  the 
requirements  of  the  case.  For  the  lower  third  I  prefer  rolled 
gold  of  Xo.  20  to  30,  of  the  most  adhesive  character,  and  annealed. 
I  also  use  for  this  part  in  many  cases  '  Eureka  gold  tilling,'  No. 
15,  with  the  greatest  advantage,  taking  up  one  or  more  of  the 
shreds,  and  working  them  in  wherever  needed.  The  first  block 
or  mat  is  passed  up  toward  the  outer  border,  until  it  reaches  the 
cervical  wall,  when  the  lower  end  is  pushed  into  place,  and  fast- 
ened by  pressure  into  the  upper  part  of  the  retaining-groove.  The 
second  piece  is  secured  in  the  same  manner  in  the  inner  or  palatal 
groove;  a  further  piece  is  forced  between  the  two,  and  directly 
against  the  cervical  wall.  When  a  sufficiency  of  gold  is  placed 
upon  these  parts  to  save  the  tooth  from  contact  of  the  points, 
the  gold  is  securely  malleted  against  the  walls  at  all  points,  pay- 
ing particular  attention  to  the  junction  of  the  tooth  with  the  ma- 
trix. In  this  way  I  proceed,  successively  introducing  and  mallet- 
ing,  until  the  cavity  is  two-thirds  tilled,  not  hastening  further  at 
any  point,  unless  the  assurance  is  reached  that  the  gold  is  per- 
fectly consolidated.  At  this  point  I  commence  and  continue  the 
employment  of  heavy  gold,  the  first  pieces  of  which  should  be  well 
fixed  in  the  gold  previously  introduced  at  the  parts  over  the  re-' 
taiuing-grooves,  and  also  worked  well  into  the  foundation.  It  is 
now  a  simple  matter  to  fill  up  the  remainder  with  quickness. 

"In  case  there  should  happen  to  beau  encroachment  by  moisture 
at  or  near  the  close  of  the  packing,  the  gold  may  be  made  smooth 
on  the  exposed  surface,  dried,  and  the  latter  part  inserted,  with 
all  the  characteristics  of  a  separated  filling.  The  form  of  the  last 
third  is  such  that,  if  inserted  with  dryness,  no  portion  can  escape. 
The  matrix  should  now  be  removed. 

"  It  will  be  found,  if  the  selection  and  adjustment  of  the  matrix 
ha-  been  correct,  that  very  little  tiling  and  cutting  down  of  the 
plug  will  be  required,  and,  in  case  the  packing  has  been  carefully 
performed,  that  the  gold  will  be  solidly  condensed  at  every  part. 
It  will  also   lie   noticed    that,  while   the  gold    is  solid,  it  will    not 

have  become  hardened  in  temper  on  the  proximal  surface,  hut 

yield-  laterally  under  the  burni-her,  not  unlike  lead  or  tin. 


502  APPENDIX. 

"I  must  at  this  point  call  attention  to  the  importance  of  the 
adaptation  of  the  filling  material  to  the  cervical  wall,  which  it  re- 
quires no  words  to  show  will  be  secured  by  this  method.  There  can 
hardly  be  a  question  that  the  general  failure  of  proximal  fillings 
is  due  to  one  or  both  of  two  causes, — the  imperfect  preparation  of 
the  cavity,  and  the  want  of  solidity  and  adaptation  of  the  gold  at 
this  part.  When  the  filling  extends  to  the  gum  or  beneath  it,  and 
the  teeth  are  not  permitted  to  come  into  apposition  here,  this 
portion  of  the  tooth,  when  well  protected,  is  least  liable  to  decay, 
as  this  is  not  the  place  where  caries  usually  commences.  And  when 
the  filling  reaches  to  the  cementum,  the  recurrence  of  caries  is  still 
less  to  be  apprehended,  since  it  is  a  clearly  established,  but  ap- 
parently overlooked,  principle  that  this  structure  is  the  least  lia- 
ble of  the  dental  tissues  to  destruction.  It  will  be  noticed  how 
seldom  failures  occur  along  the  cervical  edge  of  gutta-percha  fill- 
ings, even  when  carelessly  performed.  These  considerations  have 
been  forcing  many  to  seek  for  better  means  of  securing  adapta- 
tion, solidity,  and  smoothness  at  this  part. 

"The  instruments  for  introducing  the  filling  are  of  simple  forms 
and  direct  action,  but  they  should  be  in  fine  condition, — that  is, 
the  points  should  be  well  serrated,  and  sharp.  The  only  important 
modification  needed  are  some  pairs  of  mated  pluggers,  formed  as 
at  Fig.  135,  in  which  one  side  of  the  edge  is  considerably  longer 
than  the  other,  which  longer  side,  in  malleting,  is  con- 
'  stantly  kept  against  the  matrix;  this  effects  the  greatest 
pressure  upon  the  margins,  and  secures  with  positiveness 
the  perfect  fulness  and  the  proper  consolidation  of  the 
gold  at  these  parts.  Several  sizes  and  varied  curves  of 
this  point  are  required. 

"  The  fiuishiug  of  the  case  is  not  different  from  the  usual 
course  pursued.  In  my  own  practice  I  open  still  further 
the  inner  portion  of  the  space,  which  is  easily  done  with 
chisels  and  suitable  files.  The  peculiar  form  of  the  de- 
pression in  the  matrix  produces  a  space  which  is  considerably 
greater  on  the  inner  side,  and  which  may  be  increased  at  pleasure. 
In  many  cases,  where  the  tendency  to  caries  is  very  great,  I  chisel 
quite  freely  from  the  inner  plates  of  enamel,  doing  this  after  both 
the  adjoining  fillings  are  inserted,  cutting  down  both  gold  and 


MATRICES    FOR   PROXIMAL    FILLINGS. 


503 


Fig.  13G. 


enamel  together,  allowing  the  fillings  to  touch  only  at  the  promi- 
nent outer  part.  The  result  is  then  an  imitation  of  the  exceed- 
ingly oval  bicuspid,  the  immunity  from  decay  of  which  all  must 
have  seen  examples. 

"  Fig.  136  represents  a  transverse  section  of  two 
cases  at  a  point  immediately  above  the  grinding 
surface,  which  exhibits  the  outline  of  the  form  of 
the  cavity  and  finished  surface  of  the  gold. 

"In  full  confidence,  founded  on  considerable 
trial,  I  claim  that  this  method  of  filling  large  distal-proximal  cav- 
ities overcomes  several  of  the  chief  difficulties  and  deficiencies 
hitherto  experienced,  as  well  as  enables  greater  facility  of  per- 
formance, and  the  securing  of  excellent  results." 


I  N  D  E  X. 


Abrasion,  chemical,  38. 

Actual  cautery,  307. 

Accidents  in  the  extraction  of  tee^i,  433. 

Adaptability,  79. 

Alveolar  abscess,  339. 

treatment  of,  344. 
Amalgam,  91. 
Anaesthetics,  455. 
Appendix,  469. 

Appliances  fur  examination,  156. 
Ar-enious  acid,  281,  308. 

application  of,  310. 
Atrophy,  30. 

Attachment  of  artificial  crown,  359. 
Automatic  plugger  for  engine,  494. 

Block  filling,  194. 
Breaking  the  teeth,  447. 
Bur  drills,  101,  111. 

of  the  teeth,  43,  475. 
predisposing  causes,  52. 
exciting  causes,  ;">7. 
consequences  of,  66. 
treatment  of,  68. 
comparative  liability  to,  64. 

CaaBticS,  alkaline,   28  1. 

Chloride  of  zinc, 
Chloroform,  1">7. 

Classification  of  cavities  of  decay,  217. 
Condition!  t'»  be  observed  in  the  extraction  of  teeth,  128. 
lation,  462. 


506 


INDEX. 


Cohesive  gold  foil,  227. 

Crystal  or  sponge  gold,  89,  231,  209. 

Creosote  and  carbolic  acid,  279. 

Cylinder  filling,  194. 

Cobalt,  313. 

Dental  periostitis,  331. 

treatment  of,  335. 
Dental  caries,  43,  446. 
Denuding  of  the  teeth,  36. 
Deposits  on  the  teeth,  18. 

points  of,  20. 
Destruction  of  the  pulp,  302. 
Dislocation  of  the  inferior  maxilla,  450. 
Drills,  101. 
Drill  stocks,  106. 


Electro-magnetic  mallet,  491. 

Elevators,  400. 

Ether,  455. 

Examination  of  decays,  155. 

Excavators,  114. 

manufacture  of,  119. 
Exostosis,  33. 
Exposed  pulps,  287. 

treatment  of,  289. 

destruction  of,  302. 
Exclusion  of  moisture,  172. 
Extraction  of  teeth,  374,  406,  426. 
Extraction  of  roots,  414. 
Extracting  instruments,  383. 
Extraction  by  electro-magnetism,  465. 
Extraction  of  the  inferior  incisors,  418. 


Filling  instruments,  121. 
Filling  teeth,  154. 

examination  of,  155. 

opening  cavities,  158. 

removal  of  decay,  160; 
Filling  by  classes  and  modifications,  219. 

with  foil,  227. 
Filling  large  cavities  on  the  labial  surfaces  of  superior  incisors,  265. 


INDEX.  507 


Filling  pulp-cavities  and  canals,  315. 

Finishing  fillings,  213. 

Fitting  the  crown,  357. 

Forming  cavities,  164. 

Forming  blocks,  195. 

Forceps,  388. 

Fracture  of  the  alveolus,  451. 

General  remarks  on  filling,  74. 
Gold.  86. 
Green  tartar,  25. 

it*  origin,  26. 

treatment  of,  28. 
Gum  lancet.  403. 

Hyde's  pneumatic  plugger,  595. 
Heavy  cutting-instruments,  99. 
Hemorrhage,  434. 

treatment  of,  443. 
Hooks,  401. 

Inferior  bicuspids,  420. 
Inferior  cuspids,  extraction  of,  419. 
Inferior  third  molars,  extraction  of,  425. 
Inferior  molars,  extraction  of,  421. 
Instruments  for  filling,  99. 
Introducing  the  filling,  189. 
Introducing  the  Mocks,  198. 
Introduction,  17. 
Indications  for  extraction,  380. 
Irregularity  of  the  teeth,  28. 
effects  of,  30. 

Laceration  of  the  gums,  44'i. 
Lead  for  filling,  81. 
J.ora]  anesthesia,  162. 

Matrices,  495. 

Manufacture  of  excavator-.,  119. 

ial-  for  Idling,   7 

properties  of,  78. 
non-metallic,  95. 


508  INDEX. 

Metallic  pivots,  363. 
Mode  of  using  the  file,  137. 


Necrosis  of  the  teeth,  -10. 

cm  uses  of,  42. 
Nitrate  of  silver,  278. 
Nitrous  oxide,  459. 
Nitric  acid,  474. 

Opening  cavities,  158. 
Oxychloride  of  zinc,  94. 


Palmer's  plugging  instrument,  480. 

Pathological  conditions,  270. 

Pellets  for  Idling,  201. 

Pivot  teeth,  353. 

Platinum,  85. 

Potential  cautery,  308. 

Predisposing  causes  of  caries,  52. 

Preparations  of  gold,  88. 

Preparing  the  teeth  and  roots  for  filling,  322. 


Kemoval  of  decay,  1601 
Removal  of  the  third  molar,  415. 
Removal  of  a  wrong  tooth.  448. 
Rubber-dam  appliances,  177. 

Saliva  pump,  175. 

Screw,  401. 

Separation  of  the  teeth,  142. 

Sensitive  dentine,  271. 

Silver,  84. 

Superior  cuspids,  extraction  of,  408. 

Superior  bicuspids,  extraction  of,  409. 

Superior  molars,  415. 

Syncope,  452. 

Tannin  or  tannic  acid,  277. 
Tartar,  18. 

origin  of,  19. 

points  of  deposit,  20. 


INDEX.  509 

Tartar,  effects  of,  22. 

method  of  removing,  23. 
Terchloride  of  gold,  281. 
The  key.  384. 

Tlie  method  of  lancing  the  gums,  404. 
The  mallet,  206. 
The  file,  134. 

use  of,  137. 
Tlie  palatal  portion  of  the  crown  broken  away,  leaving  the  outer  portion 

standing — pulp  not  exposed   260. 
The  clamps,  179. 
Tin,  81. 

Treatment  of  caries,  68. 
Treatment  of  exposed  pulp,  289. 
Treatment  of  sensitive  dentine,  274. 


RK501 


T12 
1683 


Taft 

Practical  treatise  on  operative 


dentistry. 


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